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 Type:	Discover U	Discover U2	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 Date:
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:

CONFIDENTIAL - Medical Information:

Note: Discover Leadership Training respects your privacy, therefore all information on this form will be held in strict confidentiality and is used expressly for the purpose of providing you with a quality training experience that meets your specific needs. Please answer all questions as accurately as possible.

Answer all questions:

	Yes	No	Question
1.			Do you have high blood pressure?
2.			Have you ever had high blood pressure?
3.			Are you on any medications for high blood pressure?
4.			To the best of your knowledge are you pregnant?
If you answer YES to any of the follow questions please explain:
5.			Do you have any neck, back, or throat pain/injury? If yes, explain
6.			Do you or have you ever had diabetes, seizures or frequency or unexplained fainting/dizziness? If yes, explain
7.			Do you or have you ever had a heart problem? If yes, explain
8.			Are you currently taking any medication for a heart problem?
9.			Do you or have you ever had counseling or treatment for an emotional, psychological, or mental condition (currently or in the past)? If yes, explain Date of your last treatment
10.			Do you have any special dietary needs? If yes, explain
11.			Do you have any other medical conditions? If yes, explain
12.	What do you do routinely to maintain physical fitness:
13.	Birthdate:
14.	Height:
15.	Weight:

Tuition Information:

Class Tuition:	$1,549.99

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