Workshop Registration

You don’t have to be an IHG patient to take part in our workshops—all are welcome!

Please complete a separate registration form for each workshop.

If you’re registering multiple attendees, submit one form per person.

Workshop Registration Form

This field is hidden when viewing the form

Please complete a separate registration form for each workshop. If registering more than one person, a separate form must be submitted for each attendee.

Is the attendee a current patient at Indiana Health Group?

Yes

No

Workshop Choice:

Unshaken Confidence - (completed May 10th) Thank you to all who joined! This workshop will be offered again soon—stay tuned!

Let It Go - Art Therapy Workshop - Ages 13-19

Attendee Name(Required)

First Last

Preferred Name

Attendees Phone Number

Attendees Date of Birth(Required)

Month

Day

Year

Parent / Guardian Information

Parents Name(Required)

First Last

Parents Phone Number(Required)

Parents Email Address(Required)

Enter Email Confirm Email

Billing Information

Payment Authorization(Required)

I understand that workshops are not a covered service and cannot be billed to insurance. Payment is due at the time of registration. I also understand that cancellations must be made with at least 24 hours’ notice to receive a full refund.

Workshop Registration(Required)

Price:

Total Payment

Please review amount before submitting.

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date

Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045

  Security Code Cardholder Name

Billing Address(Required)

Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Consent(Required)

I agree and consent to participate in the services provided by Indiana Health Group, Inc., and its affiliated providers.

Consent(Required)

I acknowledge the Financial Policy, Patient Rights and Responsibilities, and HIPAA – Practice Notice of Privacy Practices set forth by Indiana Health Group. These documents are available at www.indianahealthgroup.com, under the Forms section of the Patient Information tab.

Parent / Guardian Signature(Required)

Date

MM slash DD slash YYYY