Advance Directives: Your Life, Your Choices Workshop Registration

Because we have space limitations, workshops are on a first come basis.

After registering, you will receive a confirmation letter, phone call, or email a few weeks prior to the workshop. If it is full, we will contact you with alternative dates or locations.

*Indicates a required field

*Workshop Location:

*Workshop date: MM/DD/YYYY

*First name:

*Last name:

Member ID #:

*Email address:

*Re-enter email address:

*Mailing address:

*City:

*State:

*ZIP code:

*Phone number for reminder call:

Will you be attending with a spouse, family member, or friend? No Yes

First name:

Last name:

Member ID # (if applicable):

Cancel

This form will be sent via email, an unsecured means of communication. We take careful measures to protect the privacy and confidentiality of any information you send us, but we can't absolutely guarantee secure transmission of your information from your computer to our servers. To register by phone, call the Your Life, Your Choices program coordinator at 1-866-458-5276.