Registration for Life Coaching Please complete the registration form below in its entirety. This will provide context to determine an initial positioning for your coaching sessions. Personal Development Registration Form What are your goals in seeking life coaching? * I am seeking a better paying job or I need to make more money. I am unsatisfied with my life’s trajectory. I am unhappy. I am looking for employment or I have been unemployed for a long time. I am interested in being married or finding the right mate. I struggle to maintain relationships. I sometimes have a hard time getting along with people or I have a hard time keeping jobs. I need more education, but I don’t know how to start or how to pay for it. I feel unfulfilled or I am trying to rebuild my life. I am a struggling single parent, and I need a support system. I want to start my own business. I want to write a book. I want to re-invent myself. OtherOther Anticipated Start Date For Our 12 week Personal Development Program (If you choose the virtual option, you must have a personal computer and internet access) * Virtually, Every Tuesday evenings at 7:00 PM Virtually, Thursday’s, 11:00 AM In person, Wednesday’s 11:00 AM In person, Thursday’s 7:00 PM I prefer weekend sessions. Please notify me about weekend schedules. Birthday * Name * First Last Name Last Phone * Email * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country I live in… Hamilton County Butler County Some place else How many children do you have? None 1 2 3 4 5 OtherOther Do you have a drivers license? Yes No Do you have a car? Yes No Gender Male Female Did you graduate from high school? Yes No Have you attended college? Yes No Have you graduated from college? Yes No Are you interested in attending college? Yes No Are you currently employed? Yes No Where do you work? Would you consider yourself underemployed? Yes No Annual Income 0-$20,000 $20,001-$45,000 $45,001-$65,000 $65,001-$80,000 $80,001-$100,000 $100,001-$250,000 $250,001-$500,00 OtherOther Source of Income (check all that apply) TANF Social Security Scholarship or Financial Aid for College Parent(s) A friend or a significant other Child Support Unemployment Trust Fund OtherOther Submit If you are human, leave this field blank.
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