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Participant Information

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Participant Name *

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Last

Address *

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State

Zip Code

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Home Phone *

Cell Phone *

Email *

Nominated By *

Relationship *

Company Name *

Type of Company *

Position / Title *

Business Street Address *

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City

State

Zip Code

Country

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone *

How should your name appear on the certificate? *

My primary reason for participating in this class is: *

How did you find out about us? *

Class Dates (Choose One) *

Signature

Terms of Acceptance: Either party may not cancel this agreement. Full attendance in each session is required. ONLY in the case of an unexpected emergency, may I attend the next class of my choice. Pulling out of a class 7 days prior (or less) to class date will result in a forfeiture of hotel & meal expenses. Refunds are not allowed. Participant acknowledges that participant has read this agreement and agrees to the terms and conditions herein.

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I, the participant for this class, warrant the truthfulness of the information provided in this application and I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the Terms of Acceptance. There are no refunds.

Date (MM/DD/YYYY) *

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