passport

Your Full Name:

Complete Mailing Address:

Daytime Phone:

Evening Phone:

Cell Phone:

Date of Birth:

Gender:

MaleFemale

Highest Educational Level Achieved:

Please briefly describe your family/home life:

What one thing in your life, if improved, would make the greatest difference to you?

Coaching Topic?

I hereby submit my application form and agree to abide by all PCCCA policies. Type name and today's date:

Your Name:
Your Email:

PCCCA Passport to Coaching
Low-Cost, Authentic, Christian Life Coaching
4-Session Package / $199 (or 49.75 per 50 minute session. )

If you would like to experience authentic Christian, Spirit-Led life coaching, why not apply for PCCCA's
Low Cost Authentic Spirit-Led Christian Life Coaching Program?

For a nominal fee, you will benefit from 4 weekly sessions with a Master Christian Life Coach candidate as
part of their practicum assignment or Certified Christian Life Coach. Sessions with Master candidates are
limited and subject to availability. Your application must indicate the topic you would like coaching on so
that we can assign the coach who is most experienced in that area. PCCCA reserves the option to assign
a Certified Christian Life Coach if they more appropriately serve your desired area of expertise.

* TERMS: Please be advised that all services must be pre-paid. In order for coaching to be of maximum
benefit to you, you need to take the actions you agree to take and you need to attend all of your sessions.
If you fail to attend or call for your session, your fees will not be refunded since your coach was there to
meet with you and needs to be paid for the session. This offer may be withdrawn at any time without prior
notice. Questions? Call our office at 239-540-4660, M-F 9-5 EDT.

Submit your application today!

INSTRUCTIONS: Please answer every question on this application form below so that we can assign
the apopropriate coach for you. If for some reason, the academy is not able to meet your coaching needs,
your payment will be refunded in full. Once the form is complete and you have verified that ALL questions
have been answerd, please click "Submit" once. Thank you.

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