Registration – Spiritual Mentoring Spiritual Mentoring Registration Spiritual Mentoring - Registration 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 this mentoring are undertaken voluntarily on your part. This mentoring 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 this mentoring. 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 mentoring. E-Signature * Payment Three-session mentoring package $360. Promo Total: $360 Payment Plan Please check this box if you will be making multiple payments for this course. Payment Type Please indicate how you will be paying for this course: PayPal / Credit Card Check Initial Payment 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 P.O.Box 914 Virginia Beach, VA 23451
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