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 you may proceed to the Checkout/Make Payment page to pay thorough the secure PayPal server. Once you have completed this registration form and made your payment your spot in the class will be reserved.

Once your 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 Certificates. *
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. *	Online Class Starting Mon. 3/5/2012 Teleclass Starting Tues. 3/6/2012 5 Day Intensive Starting Mon. 4/9/2012
How are you making your payment? If you are paying in full we must receive your full payment within 7 days of receiving this form. This is the only way we can keep your spot reserved in the class. *	I am paying through PayPal I am mailing my payment (only available if you are paying in full).
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 oayments
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 Inclusive Coaching Elective. You may choose one for no additional investment. *	No Thank You This does not apply to me Certified Christian Marriage Coach Certified Dream Achievement Coach Certified Empowerment Coach
Please choose your advanced certification. You may only choose one inclusive elective or one advanced certification. You may choose an advanced certification for no additional investment. *	No Thank You 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 *
If You Are Requesting Continuing Education Units Which Professional Organization Are You Associated With? If your organization isn't listed please confirm with your organization that your training will be approved. If you are registering for a online program please make sure that your organization doesn't require in-person or live training. *
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 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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