| Required fields (*) |
| Your first and last name*: |
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| Your contact phone*: |
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| Your e-mail address*: |
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| Your mailing address*: |
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| City*: |
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| State*: |
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| ZIP code*: |
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| Your age*: |
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| If you are under 18 y/o provide name
of your parent or guardian : |
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| Alternate phone : |
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| How did you hear about us*: |
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| Your field of occupation*: |
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| Previous Personal
Development*: |
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| If "Yes" what training have you taken
and with whom?*: |
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| Choose Your Preferred Plan*: |
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| What is your reason for taking this
training?*: |
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| What do you want to get out of this
program?*: |
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| Have you worked or studied with Mark
or Dennis in the past?*: |
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| Describe the circumstances, name of
facilitator*: |
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| Are you mentally,
emotionally and physically up for the program?*: |
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| Are your ready to
participate in a program that may challenge your current beliefs and way of
being and operating in the world?*: |
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| Do you understand that
this program represents the learning of Mark Schwimmer and Dennis Charles as
taught by Dr. Joseph Riggio in regard to the MythoSelf Model only as
indicated in the program description, and no other claims that this are
implied?*: |
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| Are your prepared to use
this material presented in this program in an ethical and moral manner that
supports your own sense of integrity?*: |
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| Do you have a sense of
humor, a sense of curiosity, a sense of wonder and eagerness and desire to
learn even more? *: |
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| Are you ready, willing and
able to take the next steps in your personal
evolution?*: |
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| Have you read the entire
application, understand and agree to all of the items and conditions within
it as they are stated?*: |
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| Based on the information
and your answers to these questions are you prepared to commit
yourself to being a participant in this training program and contributing to
your own education and the simultaneous education of others? *: |
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