Discover Leadership Training


(All fields in red must be completed)

Personal Information:
Male Female	First:	Middle:	Last:

Street Address:	Home Phone:	(include area code)
City:	Mobile Phone:	(include area code)
State:	Personal Email:
Zip:	Nominator:


Professional Information:

Company Name:	Position:
Street Address:	Phone:	(include area code)
City:	Direct Phone:	(include area code)
State:	Fax:
Zip:	Email:

Class Information:

Class Date:		Name 3 things, in order of priority, that you would like to gain from this training that will allow you to take your leadership skills to the next level. (ie. self-confidence, focus, etc.)
Class Location:

T-shirt Size:	Medium	1.
	Large	2.
	X-Large	3.
	2X-Large
		Are you a graduate of any other Leadership Training Programs?:
			No Yes, specify:

Tuition Information:

Class Tuition:	$1,199.99

Card Type:
Card Number:
Expiration Date:
Name on Credit Card:
Billing Address:
Billing City:
Billing State:
Billing Zip Code:

THERE ARE NO REFUNDS. This agreement may not be cancelled by either party.* Participant agrees to pay the full tuition and fees associated with this enrollment. Full attendance in each session is required. If participant reschedules within 30 days prior to class date, participant will forfeit $500 (except in the event of an unexpected medical emergency, whereby the participant will forfeit $250.00.) Participant MUST re-schedule within one year from date of original workshop, or the remaining balance will be forfeited. In the event that the participant does not show up for the scheduled workshop, participant understands and acknowledges that they will forfeit all tuition and fees associated with this workshop. Participant acknowledges that participant has read and fully understands this agreement before signing.
*Class dates are subject to change and/or cancellation. There will be a charge of $50.00 for all returned checks.

Your Full Name (which will serve as your signature):

Today's Date