Marsha Clark & Associates

To register, complete and submit this form.
For more information, visit www.MarshaClarkandAssociates.com
or call 972-625-3884.
Please Complete all portions of this form completely.

Personal Information

Name:		Birthday (Month/Day):
Home Address:
City:	State:	Zip:
Home Phone:	Cell Phone:
Preferred Email Address:

Employment Information

Organization:		Title:
Organization Address:
City:	State:	Zip:
Organization Phone:	Fax:
Email Address:

Sponsor Information
(Your Sponsor is the person to whom you report in your organization)

Sponsor Name:		Title:
Organization Address:
City:	State:	Zip:
Organization Phone:	Cell Phone:
Email Address:

How did you hear about this program?

	Brochure
	Website
	Referral – please specify:
	Other – please specify:

This document will be used to match you and your coach. Please provide all information as completely as possible. To ensure that you work with a coach suited particularly to your lifestyle, work-style, and aspirations, please complete this questionnaire. This is the primary information we will use to best match you with your coach.

Coach Matching Information

In what industry do you work?

How long have you been in your current role?

How many, if any, people do you lead?

Briefly describe your responsibilities:

What challenges are you currently facing in your work?

Tell us a little about your professional life (you may include a bio or curriculum vitae (CV), if desired.

How do you spend your personal time (hobbies, family, travel, reading, etc.)?

How would you describe the phase of life you are currently in?

How would you describe your overall health?

What drew you to this program?

What is your current or past experience in working with a coach?

Do you have any preferences we should know about when we match a coach with you? Consider if any issues – such as gender, race, industry expertise, life or work experience, concerns specific to women, leadership qualifications, and so on – are important to you.

Based on what you currently know about coaching, what expectations or assumptions do you have about any coaching relationship you participate in?

Please use this space to share any other information you feel is important.

The POWER of Self program has been developed by and is owned by Marsha Clark & Associates. The content, design, and structure of the program are proprietary to and protected by copyright as intellectual capital of Marsha Clark & Associates. As part of the consideration for your participation in the program, you agree to maintain the confidentiality of the program, its content, design and structure. This does not mean that you cannot use what you learn from the program or talk to others about it, but rather that you agree not to, either during the course of the program or at any time thereafter: Repeat in detail the conversations that comprise the program; Copy, duplicate or permit the copying, duplication or distribution, of all or any part of the materials provided to you during the program; Publish, disclose, resell or in any other manner reveal or use, either directly or for your own benefit or the benefit of someone else, all or any part of the content, design or structure of the program or any of the materials provided to you during the program. By signing this Agreement, you affirm that you have read and understand its terms, and agree to be bound by them.
SIGNATURE (Electronic Signature is Acceptable)	DATE

The POWER of Self program is a comprehensive program designed and developed by Marsha Clark & Associates to inspire women to explore, discover, and fulfill their potential. A valuable aspect of the program is to have the capability to reference women who have participated in the program as a means to help others become aware of the opportunities the program affords. To this end, Marsha Clark & Associates requests your permission to use your name as a reference for the program. Use of your name as a reference will be limited by the criteria checked:
	Conversational referenceability (Permission to use my name as a program participant in conversations that Marsha Clark & Associates may have as part of efforts to introduce and describe the program to others.)
	Printed referenceability (Permission to use my name as a program participant in written materials created by Marsha Clark & Associates as part of efforts to introduce and describe the program to others.)
	Video referenceability (Permission to use me in any video productions created by Marsha Clark & Associates that may be used to introduce and describe the program to others.)
	Quoted referenceability (Permission to use a specific quote from me, along with my name, in verbal or written material created by Marsha Clark & Associates as part of efforts to introduce and describe the program to others. Any quote attributed to me will be reviewed and signed off by me on a separate agreement before it is used in any manner.)
By signing this Agreement, you affirm that you give Marsha Clark & Associates permission to use your name as a reference for The POWER of Self program in the manner you have noted by marking the above listed options.
SIGNATURE (Electronic Signature is Acceptable)		DATE

The POWER of Self program is a comprehensive program designed and developed by Marsha Clark & Associates to provide women with opportunities to: Provide confident leadership Gain clarity and self awareness Create more effective working relationships Develop greater trust in supporting and mentoring women Become a powerful resource for shared learning in their organization As you make this journey, you may experience situations that evoke emotions, thoughts, and feelings. As a participant, you must take full responsibility for self-screening if such situations are a concern. This program was not designed or developed to be, or should ever be construed to be, a substitute for counseling or psychotherapy. If you are currently participating in a counseling or psychotherapy program, you should discuss your participation in this program with the counselor or therapist, and should not participate without joint concurrence between you and your counselor or therapist. By signing this Agreement, you affirm the following: Understand that participation in this program may create situations that evoke emotions, thoughts, and feelings Have made an informed and voluntary decision that participation is appropriate for you Take full responsibility for your decision to attend Take full responsibility for any transformations that you experience as a participant in this program
SIGNATURE (Electronic Signature is Acceptable)	DATE

Emergency Contact Information
(In case of emergency please contact the person listed below)

Name:
Address:
City/State/Zip:
Relationship to Self (spouse, parent, friend):
Daytime Phone:
Evening Phone:
Cell Phone:

I HAVE THE FOLLOWING SPECIAL DIETARY REQUIREMENTS
(Diabetic, Vegetarian, etc.)

Special Dietary Requirements:

Number of Particpants	Cost
1	$19,500
2	$36,000
3	$51,000
4	$64,000
5	$75,000

Initial payment of $2,500 is due to Marsha Clark & Associates by July 15, 2010.
Please make checks payable to Marsha Clark & Associates.

Flexible payment options are available as outlined in the Fee Schedule below.
For more information, contact our office at 972-625-3884.

Invoicing Information
(Where invoices for payment should be sent)

Individual Name:
Organization Name:
Organization Address:
Organization City/State/Zip:
Organization Phone:
Email Address:

Fee Schedule

I wish to be billed on the following schedule (please mark with an "X"):
	Lump-sum Payment to be invoiced September 30, 2010.
	Semi-Annual Payments to be invoiced September 30, 2010 and March 31, 2011.
	Quarterly Payments to be invoiced September 30, 2010; December 31, 2010; March 31, 2011; and June 30, 2011.
	Monthly Payments to be invoiced on the first day of the month October 1, 2010 – September 1, 2011.
	Other – please specify:

Method of Payment

I wish to pay my registration fees via:
	Check
	Credit Card *
* If you choose to pay by credit card, we will collect the pertinent information from you during Module 1 and will ask you to sign a form authorizing payment using your credit card. The following cards are accepted: American Express, MasterCard, and Visa.

I affirm that I have read and understand the PROPRIETARY INFORMATION AGREEMENT, the REFERENCE RELEASE AGREEMENT, and the COUNSELING ACKNOWLEDGEMENT AGREEMENT, and agree to be bound by them.