HireCoach Workshop

              Registration Form               

1000 Lake St. Louis Blvd., #200

 Lake St. Louis, MO 63367  

877-HireCoach (447-3262) Fax: 636- 561-5042

DarrelorPatt@HireCoach.com

     www.HireCoach.org

               Coaching/Mentoring:  Business & Personal

                MARK THE MODULE(S) for which YOU ARE REGISTERING

DATES

xx

Module I    ESW 755      ESW 455

Module II  ESW 756      ESW 456

Module III ESW 757     ESW 457

A registration deposit of $150 must be submitted along with this form.

                                              ( Please Print All)

NAME

         ___ Male

         ___ Female

ADDRESS

       Date of Birth

E-MAIL

      Special Diet?

____ Yes ____ No

Details:

HOME PHONE

CELL

EMERGENCY CONTACT/PHONE

EMPLOYER

WORK PHONE                               E-MAIL

Your Goals for the workshop:

JOB TITLE/DESCRIPTION

Please tell us how you learned of this workshop:

EDUCATION

I understand the terms and conditions for registration/credit. I also accept the workshop cancellation/withdrawal/refund policy available to me.

________________________________________                _____________

Signature                                                                                   Date