* Required fields
Name *
E-mail Address *
Have You Ever Been Convicted Of A Felony? *
No Yes
Are You 18 Years Old Or Older? *
No Yes
Have You Obtained a High School Diploma or High School Equivalency Diploma? *
Yes No
Please List Your Name As You Want It To Appear On Your Certificate(s). *
Your Complete Mailing Address (Including Zip Code and Country). *
Daytime Phone Number *
Evening or Cell Phone Number *
Gender *
Female Male
Please Indicate Your Desired Certification Program. *
Girl's Self-Esteem Certification Program Life Coach Certification Program Youth Life Coach Certification Program
Please indicate your desired program date. *
Starting Monday 12/2/2024 (Girl's Program) Starting Monday 1/6/2025 (Girl's Program) Starting Monday 12/2/2024 (Youth Program) Starting Monday 1/6/2025 (Youth Program) Starting Monday 1/06/2025 (CLC) Organization Training
If you are completing an advanced (or add on) certification program, please choose your additional certification program. This is only for the Certified Life Coach (CLC) program. *
This does not apply to me Certified Confidence Makeover Coach Certified Life Purpose & Legacy Coach Certified Radiant Mindset Coach Certified Vitality & Longevity Coach Certified Weight Success Coach
Are You Using the Payment Plan? *
No, I am paying in full Yes, I am paying in 5 payments Yes, I am paying in 10 payments My organization is making the payment
If You Are Using a Payment Plan Do You Agree to Make Your Payments on Schedule? *
This does not apply to me Yes No
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. *
Yes No
I agree that I don't have a history of unprofessional or unethical behavior that would interfere with me being a Certified Coach. *
Yes No
Please provide any additional information we may need to know.
How did you hear about us? *
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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