Guiding Mindful ChangeTM Registration Form
TO REGISTER: Print this form and mail the completed form to us.
Name:
Address:
City:                                                         State:                                                        Zip:
Phone:                                                     Email:
Web Address:
Please complete here or attach a separate sheet:

DEGREE (S):                                         LICENSE #:

Relevant Background:

Discuss your current Mindful Practices:

What would prevent you from completing this training?

Physically Challenged?       YES          NO    If Yes, what special accommodations do you require?
Please enroll me in the Mindful Coach Certification
 
 
_____________________________ starting on _____________
               CITY                                                        DATE
 
Apply my payment to the following:
 
____ $250 non-refundable deposit to reserve my space
 
____ $2775 full tuition
 
____ $950 1/3 payment due 1 month prior to start date
 
____ $950 1/3 payment due prior to start date
 
____ $950 1/3 payment 1 month after start date
 
____  I've already paid a deposit, please subtract $250 from my selection above.
 
 
Form of Payment:  
        ___ Personal Check (payable to Guiding Mindful Change)
                             
        ___ MC / Visa / Discover/ American Express via PayPal

Card #: ____________________________________________

Exp. Date: ______________________ Security code_______
 

Signature of Cardholder:_______________________________

Tuition:  Full tuition for training $2775 A non-refundable deposit of $250 is suggested to reserve your space. (Balance due 14 days prior to first day of training.)
 
Payment plan:
Initial payment of $950 is due a minimum of 1 month prior to the start date.
2nd payment due prior to the start date
3rd payment due 1 month after the start date
 
 
-- Please tell us how you heard about this program:
 
 
 
 
 
 
 
 
Refund Policy:  Cancellations must be made in writing postmarked at least fourteen (14) days prior to the training date for a refund less a $250 non-refundable deposit.  Refunds are issued within 30 days.  If, for any reason, you need to cancel within seven (7) days or are unable to complete the training, you may qualify to transfer to another training within 12 months of the original training date.

Mail Registration to:
Guiding Mindful Change
5663 Balboa Avenue, #438 San Diego, CA 92111   Phone: (619) 297-7542

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