Registration – Mentoring and Coaching Program Program Registration Mentoring and Coaching Program Registration - PTCI - Mentoring and Coaching Program Contact Information Full Name * Email Address * Phone Number * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Waiver Please review and sign the following waiver: Any and all aspects of the course are undertaken voluntarily on your part. The course is not meant as therapy or as a replacement for any other professional service that you would engage for your physical or mental health. The waiver is your acknowledgement that the Personal Transformation and Courage Institute is released from any liability related to your participation in the course. The undersigned knowingly releases and holds harmless the Personal Transformation and Courage Institute and its agents from any and all claims, suits, proceedings, costs, losses, expenses, damages, and liabilities, including but not limited to attorney’s fees and court costs, caused by and arising out of, or in connection with his/her participating in this course. E-Signature * Payment Tuition for this course is $200 per module. Please select the Module you wish to register for from the list below. Select Module Module One – Engaging the Courage to Meet YourselfModule Two – Navigating Uncertainty and OpportunityModule Three – Connecting to What is ImportantModule Four – Engaging MindfulnessModule Five – Deepening Self-CompassionModule Six – Applying the Art and Science of Well-BeingModule Seven – Building Capacity for ResilienceModule Eight – Activating Your Well-Being Plan Total: $200 Payment Type Please indicate how you will be paying for this course: PayPal / Credit Card Check To pay via PayPal account or credit card select this option and then click the "REGISTER" button below and complete the payment process on PayPal's secure website. Select the "Pay with Debit or Credit Card" option on the first page to use your card and proceed without creating a PayPal account. Please make your check payable to the Personal Transformation and Courage Institute. Please use check's memo line to indicate which course you are paying for. Mail check to: PTCI 2112 Maple St. Virginia Beach, VA 23451 If you are human, leave this field blank.