Advanced Registration

Step 1 of 5

Registering for the following weekend:*
I am a...*
Personal Details
Student Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone*
Cell Phone*
Marital Status*
Sex*
Preferred Pronouns
Birthdate*
Email*
Why do you want to attend the Advanced Course?*

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Business Details
Occupation*
Title*
Company Name*
Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Family Details
Spouse's Name
First Last
Spouse's Birthdate
Spouse's Sex
Child's Name
Child's Birthdate
Child's Sex
Child's Name
Child's Birthdate
Child's Sex
Child's Name
Child's Birthdate
Child's Sex

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Who shared the course with you? (Sponsor)
Sponsor Name*
First Last
Emergency Contacts
Emergency Contact Name*
First Last
Emergency Contact Phone*
Emergency Contact Relation*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Emergency Contact Relation*
Repeating Students Only
Date first attended Basic
Month
Day
Year
Date first attended Advanced
Month
Day
Year
Who will be attending with you?
First Name Last Name
Fore Minor's Guardian Only
Minor's Name
First Name Last Name
Full Name of Parent or Guardian
First Name Last Name
Your relationship to the minor
Minor Guardian Waiver

By filling in my name and date below, I, as parent or legal guardian of the minor named below, in such capacity, do hereby authorize the enrollment of the minor for the Pathways to Successful Living Advanced Course. I further certify that all of the responses in the minor's Advanced Course Application, are accurate and complete and that the minor does not have nor has ever had any mental disorders, epilepsy, fainting spells or other emotional, psychological or psychiatric symptoms, diseases or illnesses and that the minor is not currently undergoing nor has had treatment for any of the foregoing.
Address (if different from the minor)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name*
Date*
MM slash DD slash YYYY

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Tuition

All prices listed are in USD.

Advanced Tuition
We have included an Advanced / Leadership package. This package includes the price for Advanced and Leadership along with lodging for the Advanced Course. Packaging prices must be paid in full. Meals are not included for either course. This package gives you a savings of $500. The price for Advanced Course alone includes lodging and tuition; however, meals are not included and must be purchased by the participant. A non-refundable, non-transferable deposit of $200 must accompany your application and must be used within one year of submitting this application. If you are not paying in full, you will be put on a payment plan for the balance of your tuition which must be paid in full two weeks prior to your attendance of the Advanced Course. I agree that my monthly payments will be charged automatically on either the 5th or 20th. I understand that if my balance is not paid in full by two weeks before the first day of my course, I will lose any discount I may have received.; I understand that if I am submitting this application less than two weeks before the first day of the course, I am not eligible for a discount.
Non-Refundable Registration Fee:
A non-refundable registration fee of $200.00 USD or full payment must accompany this application to reserve your place in the class, and must be used within one year of submitting this application. If you choose to change the date from the one you originally scheduled, there will be a $200 transfer fee. For a second move there will be a $300 transfer fee to cover costs. The balance of your tuition must be received no later than two (2) weeks prior to your attendance. Only one discount can be applied at a time. The Facilitator may terminate the participation of any participant whose conduct is disruptive or inconsistent with the purpose of the course.
Tuition Option*
Payment Information
Credit Card Charges*
- By posting this electronic form with the following credit card information, I authorize Paige, Martin & Associates, Inc. to charge my credit card account.
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Terms and Conditions*
Please read carefully and check each box of the agreement.
- By checking this box, I agree that my remaining balance will be charged to my credit card two weeks before the first day of my course, unless I call the office to arrange another payment plan.
- I understand that if my balance is not paid in full by two weeks before the first day of my course, I will lose any discount I may have received.
- I understand that if I am submitting this application less than two weeks before the first day of the course, I am not eligible for a discount.
By filling in my name and date below, I acknowledge that I have read, understand and agree to all of the above terms and conditions.
Name*
Date*
MM slash DD slash YYYY
Refund Policy
Upon acceptance into the Pathways Advanced Course, it is my understanding that there will be no refund of any part of my tuition. If you choose to change the date from the one you originally scheduled there will be a $200 transfer fee. For a second move there will be a $300 transfer fee to cover costs. The Facilitator may terminate the participation of any participant whose conduct is disruptive or inconsistent with the purpose of the course.
I acknowledge that I have read, understand and agree to all of the above terms and conditions of the Refund Policy.
Name*
Date*
MM slash DD slash YYYY

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Advanced Registration

Step 1 of 5

Personal Details

Business Details

Family Details

Who shared the course with you? (Sponsor)

Emergency Contacts

Repeating Students Only

Fore Minor's Guardian Only

Minor Guardian Waiver

Tuition

Advanced Tuition

Non-Refundable Registration Fee:

Payment Information

By filling in my name and date below, I acknowledge that I have read, understand and agree to all of the above terms and conditions.

Refund Policy

I acknowledge that I have read, understand and agree to all of the above terms and conditions of the Refund Policy.

Medical and Psychological Information.