Workshop Name:
Choose one
The Discovery Workshop Mar
The Discovery Workshop Apr
The Breakthrough Course
The Discovery and Breakthrough
The Leadership Program
The Breakthrough and Leadership
Workshop Price:
Choose one
The Discovery $395
The Breakthrough $995
The Discovery and Breakthrough $1,295
The Journey (Discovery, Breakthrough and LP) $1895
The Leadership Program $795
The Breakthrough and LP $1595
(For office use only)
First Name:
Last Name:
Nickname (preferred name):
Mailing Address (Only fill out if different than billing address)
Address 1:
City:
Address 2:
State:
Zip Code:
Phone Numbers
Home:
Best time to call:
8:00am
9:00am
10:00am
11:00am
12:00pm
1:00pm
2:00pm
3:00pm
4:00pm
5:00pm
After 5:00pm
Work :
Best time to call:
8:00am
9:00am
10:00am
11:00am
12:00pm
1:00pm
2:00pm
3:00pm
4:00pm
5:00pm
After 5:00pm
# of Children:
Ages (ie: 3, 5, 12):
Referred to this workshop by:
Occupation:
Birth Date:
Please list three things you would like to accomplish by participating in this workshop:
Pricing & Refund Policy Statement
I have read, and agree to, the Pricing & Policy Statement above.
