Center for Creative Learning Course Registration Form

Fill out and submit this form to register for any course listed in "Course/Date" below.
For specific date details, see the calendar or click on More Info on a specific item below.

Course/Date*

Please select the retreat
you wish to attend; we will
contact you with more information
and to confirm your registration.

Course/Event	Location	Specifics	Start Date
Healing Warrior Hearts LGBT	Milwaukee, WI	August 2020	August 21, 2020	More Info
Healing Warrior Hearts MST	Milwaukee, WI	September 2020	September 25, 2020	More Info
Healing Warrior Hearts	Houston TX	October 2020	October 16, 2020	More Info
Healing Warrior Hearts Couples Weekend	Milwaukee WI	Oct/November 2020	October 30, 2020	More Info

Will you be a participant or staff member?*

if staff, are you a veteran or civilian?

First Name*

Last Name*

Occupation

Birth Date

(format m/d/yyyy)

Street Address

City

State

Zip

Home Phone**

(format 123-456-7890)

Cell Phone**

(format 123-456-7890)

Work Phone**

(format 123-456-7890)

Who referred you to us?

If registering as a Participant, please give us information about your service and goals

Branch

MOS

Have you served in Combat?

if yes, theater of action:

Dates of service

What is the outcome you would
like for yourself from attending
this program?

Other comments

Are you a human?*

(This helps us prevent
spam and bots)

*Required
**At least one telephone number is required