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Personal Information
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Workshop Information
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Personal & professional Aspiration
4
Logistic Information
5
Terms and Conditions
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Email Facilitator
Facilitator
*
Amelia Hirawan
Priska Devina
Ferlita Sari
Mariati Budirahardja
Ismarli Muis
Henry Rahardja
Name
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First
Last
How would you like to be called during the workshop (Do you have a nickname)?
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Date of birth
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DD slash MM slash YYYY
Gender
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Female
Male
Non-binary
City & State/Region
*
Country of residence
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Country of birth
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Cell-phone number:
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*Including Country Code Please make sure you have Whats-app downloaded onto your smartphone. We will use it for coordination and communication before and during the course.
Email address:
*
Make sure it's one you check often, as this is one of the main ways we'll be communicating with you.
Workshop Information:
Name to appear on your certificates
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What is your profession?
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Psychiatrist
Organizational Consultant
Social Worker
Psychologist
Professional Coach (Life/Executive)
Educator
Art/ Photo Therapist
Marriage and Family Therapist
Other
Do you have any accessibility issues that we need to be aware of? Any physical disability or difficulty?
If you do, please mention what it is and how we can assist you.
Do you have any dietary or allergies we need to be aware of? Gluten free/ Lactose sensitivity/ nut allergies etc.
Are you currently dealing with a medical condition that we need to be aware of?
If so, please mention what it is and if there is any way we can assist you.
Have you ever taken any medication (psychiatric or due to a medical condition)?
YES
NO
Are you currently taking any medication (psychiatric or due to a medical condition)?
YES
NO
Parts of the training might be recorded and photographed. While this is mostly for creating memories for you from the experience, we may use some photos for upcoming marketing purposes. Do we have your permission to photograph you during the training?
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YES
NO
Personal & Professional aspirations
What do I wish to gain from the workshop on a personal level?
What do I wish to gain from the workshop on a professional level?
In which field do I still have unleashed potential?
Career
Relationship
Money
Sexuality
Family & Friends
Health
Personal growth
Is there something that you would like to share about yourself?
Logistic information
Which tools version do you want to have?
*
Bahasa Indonesia
English
Name to appear on your receipt/invoice
If you'd like it to appear as the name you mentioned above, you can skip this question
Tax ID / VAT ID?
Billing address
Street Address
City
State / Province / Region
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Terms and Conditions
Please note that by submitting this form, you are accepting that you have read and agreed to the following terms and conditions.
Professional & Marketing information news
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I accept
I don't accept
I agree that as part of the workshop registration I will share with the participants a form in which they will need to agree:
Share their personal details with Points of You Indonesia (full name and contact info) & Confirm receiving news, newsletters, and special offers from the Points of You Indonesia.
Liability agreement
*
I accept
I don't accept
The Creative Practice workshop is an energitic, practical and creative workshop. This training is an opportunity to experiance a powerful professional and personal exploration of learning, reflecting, letting go and just being. Points of You® Academy official workshops are not a substitute for psychiatric, or psychotherapeutic treatment, but may complement a therapeutic process and facilitate. Points of You® always strives for every participant’s well-being, it is the responsibility of each participant to take care of themself. By submitting this form, you accept that you are solely responsible for your physical and mental well-being during the training and also for your personal items. I accept/ I don't accept
Cancellation Policy
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I accept
I don't accept
Recommendation for cancellation policy :
All the investment will return in credit points that can be used to apply another schedule of Points of You official workshop or Points of You tools purchasing.
© 2019 Points of You® Indonesia