Mind of State

First Name *
Last Name *
Email *
Phone Number
Street Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
DISCOUNT CODE	If you are a Lifelong Learner Member or a Student Member, please insert your member code here to claim your special price for this program.
Email newsletter	Please add my name and email for upcoming newsletters and future events
Event Cancellation Policy (Retreat, 14 days)	Full refunds for registrations will be provided up to 14 days prior to an event. Cancellations made 13-6 days prior will receive a 50% refund. There is no refund for registration cancellations made within 5 days of your arrival or if you do not show up or leave a program or event early. The Retreat at Pacifica reserves the right to cancel any program at any time. In this instance, you will be refunded in full.I agree to the above waiver
Please list your state and/or country: *
If you are a current PGI student, please enter your Pacifica email address	Only needed if you selected the Pacifica Extension Student Membership Rate
If you are a PGI Alumni, please enter your graduation year	Only needed if you selected the PGI Alumni Rate
Select Your License Type	LMFT LCSW LPCC LEP Psychologist Please select your current license. Only needed if you purchased the optional CECs
Enter Your License Number	Only needed if you purchased the optional CECs
Is this your first time taking a Pacifica Extension program? (Formally known as The Retreat and Pacifica Online) *	Yes No

First Name
Last Name
Card Number *
Card Expiration *	Month Year
Card Security Code	usually a 3 digit code on back of card

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