Daring You to Be YOU! Consultant Application Form

Daring You to Be YOU! Consultant Program Application

To become a consultant and sign up for our training, please complete all questions.
Name*

First NameLast Name
Business Name:
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Home Number

Area CodePhone Number
Cellular Number

Area CodePhone Number
Work Number

Area CodePhone Number
What are your specific training goals?*
Are you currently a Fitness Professional, Life Coach, Health Professional (i.e., Nurse, Doctor, etc.) or Mental Health Professional?*

YesNoI rather not disclose that information.
Are you currently currently licensed or certified to provide therapeutic services?*

YesNoI rather not disclose that information
Are you currently providing fitness, health, or mental health services to clients?*

YesNoI rather not disclose that information
Will you have issues participating in a virtual coaching experience?*

YesNoI do not know yet
Training Date: Webinar times will be 4pm PST, 6pm CST, 7pm EST*
Select the date and training format that you desire.
I Certify....

that I am a Fitness Professional, Life Coach, Health Professional, or Mental Health Professional who has received formal training and education to provide services to clientele. I understand that as a consultant, I am utilizing the products to inform and motivate clients during their weight loss program. I am knowledgeable or will become knowledgeable of the ethical code of conduct applicable to those in the mental health profession. I will not provide advice or services outside of my realm of expertise and only utilize the products offered for the purposes of informing and coaching my clients. (Click on the following link for the APA Code of Conduct (http://www.apa.org/ethics/code/)
Signature*
Signature date
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My Products : Please allow 7-10 days to receive training materials.

Webinar Consultation Training Program$499.00

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Subtotal $0.00Tax $0.00Shipping $0.00Total $0.00

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Daring You to Be YOU! Consultant Program Application

I Certify....

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