Mycelium Cafe Wheel of Consent Registration Mycelium Cafe Wheel of Consent Registration Please fill out this form to register for the Wheel of Consent Workshop, to be held on November 22nd - online - and November 28th and 29th - in person. This workshop is being presented free of charge by onmyplanet.ca and the Mycelium Cafe, the Mycelium Cafe is funded by the REACH program, which is part of The New Horizons for Seniors program at Service Canada. The description of the practice of the Wheel of Consent was sent out to the Mycelium Cafe email list. If you have not read the full description of the Workshop please find it here: https://onmyplanet.ca/woc-description/ The Workshop will be facilitated by Helena de Felice and Angelica Miller (bios and links in full description) On registration, you will be asked for a $50.00 deposit that will be returned to you after completing the workshop. If you cancel after 12 noon on Thursday Nov. 19th, which is 72 hours prior to the start of the workshop on Sunday November 22nd, you will forfeit your deposit. If submitting a deposit is a critical barrier for you, please email lulu@onmyplanet.ca to discuss an alternate arrangement. Registration is in two stages: 1. Submit this completed form - you will then receive an email from onmyplanet.ca with instructions to send an e-transfer deposit of $50.00. 2. When your deposit has been received, you will receive a second email confirming your registration in the workshop. Workshop participants are limited to 16 people. If the workshop is full your name will be put on a waiting list. You will receive an email informing you that you are on the waiting list. You will not be asked for a deposit until you are being offered a spot in the workshop. Your deposit will be returned after the completion of the workshop. If you have any questions or concerns about the workshop or the Mycelium Cafe please email lulu at onmyplanet.ce Today's Date * First Name * Last Name * Phone Number * email address * Demographics 01 I'm over 55 and identify as Indigenous - First Nations, Métis, and/or Inuit Demographics 02 I'm over 55 and a Francophone Demographics 03 I'm over 55 and identify as 2SLGBTQIA+ Deomgraphics 04 I am over 55 and identify as non-binary, trans, or in another way on the gender spectrum Demographics 05 I'm over 55 and a person with a visible disability Demographics 06 I'm over 55 and a person with an invisible disability Demographics 07 I am over 55 and have a low income Demographics 08 I am over 55 and am socially isolated Demographics 09 I am over 55 and am geographically isolated Demographics 10 I am over 55 and a new immigrant Demographics 11 - Gender Expression I identify as Cis Gender Demographics 12 - Gender Expression I identify as Trans Gender Demographics 13- Gender Expression I identify as Non-Binary Demographics 14 - Gender Expression I identify as Gender Non-Conforming Demographics 15 - Gender Expression I identify as Gender Queer Demographics 16 - My gender was not listed above and I identify as: Age Group I'm under 25 years of age Age Group I'm between the ages of 25 and 34 Age Group I'm between the ages of 35 and 44 Age Group I'm between the ages of 44 and 54 Age Group I'm between the ages of 55 and 64 Age Group I'm between the ages of 65 and 74 Age Group I'm between the ages of 75 and 84 Age Group I'm older than 84 What municipality do you live in? Kosapsum Nation What municipality do you live in? Songhess Nation What municipality do you live in? City of Victoria What municipality do you live in? Oak Bay What municipality do you live in? Saanich What municipality do you live in? Gulf Islands What municipality do you live in? Sidney What municipality do you live in? North Saanich What municipality do you live in? Central Saanich What municipality do you live in? Highlands What municipality do you live in? View Royal What municipality do you live in? Langford What municipality do you live in? Metchosin What municipality do you live in? Colwood What municipality do you live in? Sooke What municipality do you live in? Somewhere else in BC What municipality do you live in? I live outside of BC Where I live was not on the list - I live in: Have you participated in The Mycelium Cafe in the past? Yes No I would like to go, but haven't been yet. Please add me to the Mycelium Cafe email list Have you participated in a Wheel of Consent workshop in the past? Yes No If Yes - with who? Use the following text box Other - please explain in the following text box My previous experience with Wheel of Consent is: What are you hoping to gain from the workshop? At the in-person workshop, lunch will be provided. Please tell us if you have any food allergies or conditions that we should know about. * Celiac Gluten Free Lactose Free Vegetarian Vegan I eat everything I have severe allergies to the following foods: Is there anything else you would like us to know before you attend this workshop? Submit If you are human, leave this field blank. Δ