Contact Information Emotional Freedom Technique (EFT) for Health and Well-being - Registration Personal Information Event Date* - Select Event Date - Event Date is Required First Name* First Name is Required Last Name* Last name is Required Address* Address is Required Address 2 City* City is Required State* Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana International Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming State is Required Zip Code* Zip Code is Required Email Address* Email is Required Invalid Email Address Phone* Phone is Required Invalid Phone Number Alt Phone Invalid Phone Number Gender MaleFemale Partner's Name(Optional) How Did You Hear About Us?* Select Internet Search From a Friend Healthcare provider Community Calendar Email From a Caregiver From Newspaper Other How Your Hear About Us is Required Secure Payment Information Billing Address* Billing Address is Required City* Billing City is Required State* Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana International Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Billing State is Required Zip Code* Billing Zip Code is Required Name On Card* Name on Card is Required Credit Card Type* Select Visa MasterCard American Express Discover Credit Card Type is Required Credit Card Number* Credit Card Number is Required Invalid Credit Card Expiration Date* 010203040506070809101112/2023202420252026202720282029203020312032203320342035203620372038 Invalid Expiration Date Security Code* Security Code is Required Total $35.00 Register