Register for Life Coach Certification Program

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. 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. Thank you in advance!

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? *
Are You 18 Years Old Or Older? *
Have You Obtained a High School Diploma or High School Equivalency Diploma? *
Please List Your Name As You Want It To Appear On Your Certificate(s). *
If you are completing organization training please list the name and address of your organization. If you are not please put N/A. *
Your Complete Mailing Address (Including Zip Code and Country). *
Daytime Phone Number *
Evening or Cell Phone Number *
Gender *
If you are completing an advanced certification program, please choose your advanced certification. *
Please Indicate Your Desired Class Start Date. *
Are You Using the Payment Plan? *
If You Are Using a Payment Plan Do You Agree to Make Your Payments on Schedule? *
If you are using the payment plan and you would like your certification(s) when your program has ended please list your date of birth (This is only used if you default on your payments and we can't reach you). If this does not apply to you please put N/A. *
If you are using the payment plan and you would like your certification(s) when your program has ended please list the last 4 digits of your social security number (This is only used if you default on your payments and you can't be reached). If this does not apply to you please put N/A. *
If you are using the payment plan and you would like your certification(s) when your program has ended please provide the name of three references, and their telephone numbers (This is only used if you default on your payments, and you can't be reached). If this does not apply to you please ut N/A. *
If you are using the payment plan and you would like your certifications when your program has ended please list your employer's address and telephone number (This is only used if you default on your payments, and you can't be reached). If this does not apply to you please put N/A. *
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. *
I agree that I don't have a history of unprofessional or unethical behavior that would interfere with my being a Certified Coach. *
Please provide any additional information we may need to know.
Please type in your name and today's date to state that you agree with what is marked on this enrollment form. Once you submit this form please proceed to the Checkout/Make Payment page to complete your payment. We will electronically receive this form, and you will be sent your new student and class information within 24 hours. We strive to provide you the information within a few hours (excluding after business hours, holidays or weekends, then it will be the next business day). Thank you! *


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