One form must be completed for each individual attendee, even if you are registering at the team rate.
Indicates required field
First Name:
Last Name:
Title Category:
Address: (This address will be used to mail your welcome gift)
Phone: Example: xxx-xxx-xxxx
Cell: Example: xxx-xxx-xxxx
Email: (This email will be used to provide access to the event)
Additional Emails for Confirmation:
I heard about the Virtual Gathering from: Pioneer Network Website Internet search
Colleague Email Social Media State Coalition
Another organization (Please specify)
Other (Please specify)
Pioneer Network is offering a "TEAM" discounted registration fee. "TEAM" is defined as 5 or more attendees registering from the same organization. Those receiving other discounts do not qualify toward your team numbers. If you are unsure of the attendees’ names at this moment, please register as TBD. Should you have any questions regarding your "TEAM" registration, please email our registrar at

Registration Type

Team / Individual

Regular Registration
(includes CEs, welcome gift, event access September 1-3 and access to all sessions for 45 days post-event)
Team Registration
(include CEs, welcome gift, event access September 1-3 and access to all sessions for 45 days post-event *You will need to register each person individually)
(5 or more people from same organization/company no matter location. Fee is per person)
Organization Registration for those not requiring CEs
(includes one welcome gift, event access September 1-3 and access to all sessions for 45 days post-event)
Unlimited number of people from one location/site/building

Please mark your selected registration fee.

Registration Code
If you have received a registration code, please enter your code here. The appropriate price will appear below.

Please select the license type, provide license number(s) and state(s) below. Please note these will be emailed to you within 2 weeks of the end of the Gathering.


License #(s)

Social Workers
Activities Professionals
Registered Dietitians
Contribute to the work of Pioneer Network and the culture change movement. Your gifts are tax deductible, and all of them, large and small, are deeply appreciated.
Donation Amount:
Total Due:
Please check one: Visa
American Express
Check - Send payment to Pioneer Network
                                              c/o OPTimum Planning
                                              424 General Early Drive
                                              Harpers Ferry, WV 25425
Name of Cardholder:
Card Number:
Expiration Date: (mmyy - ex: 0720)
Security Code:
Card Billing Address:
By submitting this form, I am authorizing Pioneer Network to process my credit card for payment as indicated above. If paying by check, I acknowledge that payment must be received within 45 days of invoice. If registration is part of a team discounted registration, I agree that any change which results in my organization dropping below the minimum for team requirement will result in rest of the registrations being charged the normal registration fees. I acknowledge responsibility for those changes. All cancellations must be submitted in writing and must be received by August 1, 2020 to be eligible for a refund, less a $50 administrative/cancellation fee. No requests for refunds will be accepted after August 1, 2020. Attendee substitutions may be made at any time, without penalty. To submit cancellation and/or substitution requests - email to, fax to 304.566.9911 or mail to Pioneer Network, c/o OPTimum Planning, 424 General Early Drive, Harpers Ferry, WV 25425.
Pioneer Network