Peer Coaching Exchange Intake
(Coaching Circles - Alumni)
Registration Information
Training Status
(please mark which one applies to you)
{"type":"radio","name":"__generic6","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the above options.","options":"I am currently in an ICF Affiliated ACTP or ACSTH Program\nI am a graduate of an ICF Affiliated ACTP or ACSTH program"}
{"type":"textarea","name":"__generic8","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"If this question does not apply just type \"N/A\" (for not applicable)","height":80,"placeholder":"If 1st or 2nd choice marked in this question, please list Program name and level completed (for example: ABC Training, ACC; OR - a 60 hour or 125 hour course)"}
{"type":"radio","name":"__generic9","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Does not apply to me"}
(please mark which one applies to you)
{"type":"radio","name":"__generic10","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"I am currently in a coaching program through IAC, EMCC, or CCE\nI am a graduate of another Coaching Program (IAC, EMCC, CCE)\nI have completed a Coaching Program without Certification (UDEMY, Coursera, Private Training Organization with non-affiliation to above)"}
{"type":"textarea","name":"__generic11","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"If this question does not apply just type \"N/A\" (for not applicable)","height":80,"placeholder":"If 1st, 2nd, or 3rd choice marked in this question - please list Program name and level completed (for example: ABC Training, Board Certified Coach)"}
{"type":"radio","name":"__generic12","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Does not apply to me"}
Are you an Alumni of any of the following ACTP programs?
{"type":"checkbox","name":"__generic14","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Goal Imagery Institute (ICF affiliated) 60+ or more hours\nThe Coach Training Academy (ACC or ICF affiliated) 60+ or more hours\nNot an Alumni"}
(we offer discounts for Alumni of these programs)
If none of the above applies - STOP here! You are not able to participate in our Coaching Circles at this time. Please come back when you have either enrolled in, or completed one of the above programs.
If you DID complete the above section please continue below.
Coaching Circle Start Date Interested In (first choice)
Click drop down and choose one:January - May (starts 1st week of January)April - September (starts 1st week of April)July - December (starts 1st week of July){"type":"select","name":"__generic","width":100,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Click drop down and choose one:\nJanuary - May (starts 1st week of January)\nApril - September (starts 1st week of April)\nJuly - December (starts 1st week of July)"}
Coaching Circle Start Date Interested In (second choice)
Click drop down and choose one:January - May (starts 1st week of January)April - September (starts 1st week of April)July - December (starts 1st week of July)N/A (not interested in another choice){"type":"select","name":"CoachingCircleStartDates","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Click drop down and choose one:\nJanuary - May (starts 1st week of January)\nApril - September (starts 1st week of April)\nJuly - December (starts 1st week of July)\nN/A (not interested in another choice)"}
Coaching Circle Start Date Interested In (third choice)
Click drop down and choose one:January - May (starts 1st week of January)April - September (starts 1st week of April)July - December (starts 1st week of July)N/A (not interested in another choice){"type":"select","name":"__generic2","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Click drop down and choose one:\nJanuary - May (starts 1st week of January)\nApril - September (starts 1st week of April)\nJuly - December (starts 1st week of July)\nN/A (not interested in another choice)"}
Personal Information
Are you 18 years old or older?
{"type":"radio","name":"__generic4","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
Legal Name: {"type":"text","name":"__generic20","width":65,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
First Name
{"type":"text","name":"__generic21","width":65,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Last Name
What Name Should I Use In Our Communications?
{"type":"text","name":"__generic5","width":60,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
What is the best phone number to contact you at?
{"type":"text","name":"__generic3","width":50,"value":"","size":"Normal","validation":"NE","validationMessage":"Please enter a phone number.","placeholder":""}
What Time Zone Are You In?
choose oneAlaska Standard Time (AKST)(Arabic) Egypt Standard Time (ART)Argentina Standard Time (AGT)Atlantic Standard Time (AST)Australia Central Time (ACT)Australia Eastern Time (AET)Bangladesh Standard Time (BST)Brazil Eastern Time (BET)Canada Newfoundland Time (CNT)Central African Time (CAT)Central Standard Time (CST)Chamorro Standard TimeChina Taiwan Time (CTT)Eastern African Time (EAT)Eastern European Time (EET)Eastern Standard Time (EST)European Central Time (ECT)Greenwich Mean Time (GMT)Hawaii-Aleutian Standard Time (HST)Indiana Eastern Standard Time (IET)India Standard Time (IST)Japan Standard Time (JST)Middle East Time (MET)Midway Islands Time (MIT)Mountain Standard Time (MST)Near East Time (NET)New Zealand Standard Time (NST)Pacific Standard Time (PST)Pakistan Lahore Time (PLT)Phoenix Standard Time (PNT)Puerto Rico and US Virgin Islands Time (PRT)Samoa Standard Time Solomon Standard Time (SST)Universal Coordinated Time (UTC)Vietnam Standard Time (VST){"type":"select","name":"__generic7","width":40,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"choose one\nAlaska Standard Time (AKST)\n(Arabic) Egypt Standard Time (ART)\nArgentina Standard Time (AGT)\nAtlantic Standard Time (AST)\nAustralia Central Time (ACT)\nAustralia Eastern Time (AET)\nBangladesh Standard Time (BST)\nBrazil Eastern Time (BET)\nCanada Newfoundland Time (CNT)\nCentral African Time (CAT)\nCentral Standard Time (CST)\nChamorro Standard Time\nChina Taiwan Time (CTT)\nEastern African Time (EAT)\nEastern European Time (EET)\nEastern Standard Time (EST)\nEuropean Central Time (ECT)\nGreenwich Mean Time (GMT)\nHawaii-Aleutian Standard Time (HST)\nIndiana Eastern Standard Time (IET)\nIndia Standard Time (IST)\nJapan Standard Time (JST)\nMiddle East Time (MET)\nMidway Islands Time (MIT)\nMountain Standard Time (MST)\nNear East Time (NET)\nNew Zealand Standard Time (NST)\nPacific Standard Time (PST)\nPakistan Lahore Time (PLT)\nPhoenix Standard Time (PNT)\nPuerto Rico and US Virgin Islands Time (PRT)\nSamoa Standard Time \nSolomon Standard Time (SST)\nUniversal Coordinated Time (UTC)\nVietnam Standard Time (VST)"}
How did you hear about this program?
{"type":"textarea","name":"__generic17","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"Who is the person that referred you, or how did you learn about this program?"}
I am seeking Coaching Exchange for the following:
{"type":"radio","name":"__generic15","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the above options.","options":"I am accumulating hours towards a Certification/Affiliation\nI am maintaining requirements for a current Certification/Affiliation\nI am enrolled in or have completed a training program and I just want Coaching practice.\nOther"}
{"type":"text","name":"__generic16","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"If other, please explain"}
Which Choice interests you most?
{"type":"checkbox","name":"Referral","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the above options.","options":"1 Circle (may include 3-6 coaches) - $75.00\n2 Circles at once (may include 3-6 coaches) - $150.00"}
Anything you would like to share or that we should know about you?
{"type":"textarea","name":"__generic19","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"If nothing to add or comment about just type \"N/A\" (for not applicable)","height":80,"placeholder":"This is a good time to ask any questions or get any clarifications."}
If you have questions, please reach out to us.
Our business hours are:
Tues - 10am-6pm EST
Thur - 10am-6pm EST
Fri - 10am-3pm EST
Sat - 10am-2pm EST
We are honored to be a part of a Coaching Exchange with you.
Let's get started.
Sincerely,
616-730-1204
Caren Robinson
