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CCLC Training with Dr. Bush Enrollment Form

INSTRUCTIONS: Prior to completing this Enrollment Form, please read the General Policies & Student Agreement
as this form will require that you have read it and agree to these policies and terms. Then continue on to
answer every question on this enrollment form so that we can assess your acceptance as a student for one of our programs. Once the
form is complete and you have verified that ALL questions have been answered, please click "Submit" once. Thank you.

DO NOT use quote marks("). It will cause your answers to be cut off.

CCLC Teleclass Enrollment Form

Please carefully review the student polices available at the link above right and answer every question on this enrollment form so that we can assess your acceptance as a student for the Certified Christian Life Coach program. Once the form is complete, please click submit. Thank you.

Your Full Name (As you would like it to appear on your certificate):

Complete Mailing Address:

Daytime Phone

Evening Phone or Cell Phone

Date of Birth

Highest Educational Level Achieved:

Have you taken any other life coach training, and if so please explain when and where:

Your Statement of Faith:

Please explain how you expect to use your Christian Life Coach certification:

What is your current profession?

Which payment option do you plan to use (full payment of $1597, 5 installments of $340 or $250 DOWN + 9 Mthly Pays of - $159 USD ea ?

Do you understand that enrollment in this teleclass is available on a first come basis. Do you understand that your seat will not be reserved without making your payment / first payment?

BLI / PCCCA GENERAL POLICIES AND STUDENT AGREEMENT: I have read and agree to be bound by the current student policies and agreement as found at the link top right on this page.

YesNo

Please type your name and today's date below to validate your agreement to the above mentioned agreement and policies:

Other comments or special considerations:

Your Name:
Your Email: