Men's Pathway to UnityRegistration Form

Men's Pathway to Unity
Registration Form

NOTE: The following registration is good for one participant. This is an interactive virtual program, and each participant will need their own computer/laptop/device. Please let us know if you have any questions.

Contact Details

Salutation

First Name

Last Name

Suffix

Phone Type

HomeWorkCell

Home Phone

Work Phone

Cell Phone

Preferred Contact Method

PhoneEmail

Address Type

HomeWork

Mailing Address

City

State/Province

Postal Code

Country

Organization / Congregation / School

Title

Race/Ethnicity:

Other Race/Ethnicity (please specify):

Faith Tradition:

Other Faith Tradition (please specify):

Denomination:

Other Denomination (please specify):

Date of Birth

How did you hear about this program?

Other (please specify):

Discussion Dates [Please plan to attend all discussions if possible]:

Have you ever attended an organized men's discussion group before?

YesNo

What is one thing you are hoping to get out of this group?

Do you have any notes or concerns for the organizers?

Program Fees

Interfaith Philadelphia is committed to making our programs accessible to all. A limited number of reduced cost registrations are available upon request. An additional gift added to your registration fee will provide scholarships for this program and others. Interfaith Philadelphia is a registered 501(c)(3) nonprofit, non-sectarian organization.

I would like to pay the following way:

$50 Individual Standard Rate - Pay Online (Visa, Mastercard, American Express, or Discover)Request ScholarshipCCP Partner Rate (for those who live in South Philadelphia, Kensington/Fairhill, or West Philadelphia)

I would like to subsidize another person's attendance with an additional contribution

Contribution Amount:

Payment Information

Name on Card

Billing Email

Card Number

Code

Total amount your card will be charged today

Campaign ID

Contact Information