Women’s Power Circles Joining Form ConfidentialDate* Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Cell*I can leave a message*YesNoEmail* Please X if it’s okay that I*Yes email youNo email youCan I let your fellow circle members have your email address?*YesNoAge*Occupation*What is the starting date of the circle you wish to join?* Who are you joining the circle with? First Name Last Name What are your goals?*How did you hear about Women’s Power Circles?*FriendDoctorInternetBy signing you agree to comply with the following terms and conditions:1. Keep other members’ stories and information confidential. You are free to talk about your circle experience, goals, and personal story, and the themes discussed in the circle. 2. Sign into your online circle meeting 5 minutes before it starts. Make sure your audio and video are working and you have a quiet and private place to talk. 3. Commit to attending every circle meeting. If you cannot attend a meeting please email Rosjke 48 hours before the start of the meeting. 4. Payment is due before the start of the circle to secure your place. No refund will be given within 4 weeks of the start of the circle or for missed circle meetings. Prior to 4 weeks, a full refund will be given. 5. Women’s Power Circles are not therapy groups. They are for self-development and informational purposes only, and you are responsible for the choices you take. If I have any concerns about your health or emotional wellbeing, you agree to seek appropriate professional support and advice outside of the circle. My signature below declares that I understand and agree with the above terms and conditions. I understand that Women's Power Circles offers information of a general nature and that I am responsible for what I choose to do with the information and for my own actions and self-care. Signature*Anti Spam control This iframe contains the logic required to handle AJAX powered Gravity Forms.