30-Day Empowering Wellness Initiative Registration Form: Company
THANK YOU for registering your company for the Living Spirit Therapy Services 30-Day Empowering Wellness Initiative! We understand that finances are incredibly tight and unpredictable for businesses at this time. We are hopefully that this will help improve support, morale, productivity, and overall health of your employees.
Company Contact Person
Name of Company
Name of Contact Person
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Is there a positive habit that you want to establish in the coming months?
What do you currently do, or would you like to do, for self-care? What activities contribute to your overall wellness?
How did you hear about the LSTS 30 Day Empowering Wellness Initiative?
How Does Your Team Register?
Please ask anyone on your team who is interested in participating to register individually, selecting the box that says "my employer is covering the tab" under payment. This will allow us to collect their email addresses to share information and to find out what they have been doing or would like to do for self-care.
The link for team member registration is: https://hipaa.jotform.com/201406652142040
Payment
Payment Method
You may pay by check if you reside in MN. Please contact melissa@livingspirittherapy.com if you would like to pay by check
Credit Card. Use the secure form below for credit card payments.
Rates
$100 for whole team access (for staff in one location) for hospitals, hospice, homecare, and long term care facilities
$75 per employee for 1-2 employees. Free enrollment for contact person
Whole team access for companies with 3 - 10 employees:$200
Whole team access for companies with more than 11 employees:$400
If you are paying by check you don't need to complete the bottom section of this form. Continue if you are paying by credit card.
Enter Appropriate Rate From Above
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USD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Phone Number
-
Area Code
Phone Number
Submit
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