You may use this form to register for your coach certification program online 24 hours a day. Please answer all of the questions and then submit the form. If any question is not applicable, please put N/A in the box.

Once this form is completed please proceed to the Checkout/Make Payment page, to pay through the secure PayPal server (unless you are registering for private or organization training).

If you are registering for the online program, your spot in the class will not be reserved until you have completed this registration form, and made your payment. So we ask that you please not submit this form until you are ready to make your payment. This allows us to keep accurate track of available class space.

Once your registration and payment is received, within 24 hours (excluding weekends and holidays) you will receive new student coach information via e-mail, and then you will be on your way the career of a lifetime! 

* Required fields
Name *
E-mail Address *
Have You Ever Been Convicted Of A Felony? *	No Yes
Are 18 Years Old Or Older? *	No Yes
Have you obtained a High School Diploma or G.E.D.? *	Yes No
Name As You Want It To Appear On Your Certificate(s). *
Complete Mailing Address (Including Zip Code and Country). *
Daytime Phone Number *
Evening or Cell Phone *
Gender *	Male Female
Please indicate your desired class start date. *	Life Coach-Online Class Starting Mon. 6/4/2012 Life Coach-Online Class Starting Mon. 7/2/2012 Life Coach-Teleclass Starting Thurs. 7/12/2012
Are you using the payment plan? *	No, I am paying in full Yes, I am paying in 4 payments Yes, I am paying in 6 payments
If you are using the payment plan do you agree to make your payments on schedule? *	This does not apply to me Yes No
Please choose your advanced certification program. This option is only for the Certified Life Coach training program. *	This does not apply to me Certified Christian Life Coach Certified Girl's Self-Esteem Coach Certified Youth Life Coach
Previous Certificates/Diplomas/Degrees *
Professional Background *
How Do You Plan On Using Your Certification? *
I agree to follow the ethical and professional guidelines of The CASE Institute. *	Yes No
I agree that I don't have a history of unprofessional or unethical behavior that would interfere with my being a Certified Coach. *	Yes No
Please provide any additional information we may need to know.
Please type in your name and today's date to state that you agree to what is marked on this enrollment form. *

I have read and agree to the Privacy Policy *

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