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(847) 478-1088
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Advanced Registration
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Registering for the following weekend:
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May 15-19, 2019
August 14-18, 2019
November 6-10, 2019
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Please select student status
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Personal Details
Student Name
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Address
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Street Address
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Birthdate
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Email
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Why do you want to attend the Advanced Course?
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Business Details
Occupation
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Title
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Company Name
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Company Address
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Street Address
Address Line 2
City
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Armed Forces Americas
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State
ZIP Code
Family Details
Spouse's Name
First
Last
Spouse's Birthdate
Spouse's Sex
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Male
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Child's Name
Child's Birthdate
Child's Sex
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Male
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Other
Child's Name
Child's Birthdate
Child's Sex
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Male
Female
Other
Child's Name
Child's Birthdate
Child's Sex
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Who shared the course with you? (Sponsor)
Sponsor Name
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Emergency Contacts
Emergency Contact Name
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First
Last
Emergency Contact Phone
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Emergency Contact Relation
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Emergency Contact Name
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First
Last
Emergency Contact Phone
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Emergency Contact Relation
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Repeating Students Only
Date first attended Basic
MM
DD
YYYY
Date first attended Advanced
MM
DD
YYYY
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Name
*
Date
*
Date Format: MM slash DD slash YYYY
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
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Please select an option
$200 (Deposit)
$1995 (Full Payment)
$1295 - (Young Adult / Repeat)
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 Number
*
Cardholder Name
*
Credit Card Expiration Date
*
Credit Card Security Code
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Card Holder Zip Code
*
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
*
Date Format: 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
*
Date Format: MM slash DD slash YYYY
Medical and Psychological Information.
Due to the participatory nature of the course, the following information is required to attend. This is done in order to provide the best learning environment possible for you and the other participants. Please answer the following questions by checking the appropriate response. Your answers are kept confidential except for possible disclosure to your physician, psychiatrist, psychologist or therapist, if applicable. If you have any questions or concerns regarding the following, please contact the Pathways office.
1. Have you any history of Psychiatric Disorder?
*
Yes
No
2. Have you ever been institutionalized for mental illness?
*
Yes
No
3. Are you now undergoing, or have you within the last one (1) year undergone treatment by a psychiatrist or psychologist for a psychiatric disorder or mental illness?
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The Basic Course is based on an educational model, not a medical model. None of the Pathways staff are licensed psychiatrists or psychologists.
Yes
No
4. Do you have any physical symptoms, diseases, illnesses, or disabilities?
*
Yes
No
5. Have you been hospitalized for a physical injury within the last twelve (12) months?
*
Yes
No
6. Are you now undergoing, or have you within the past six (6) months undergone treatment by a medical doctor?
*
Yes
No
7. In case of emergency I give my consent to Pathways to disclose any part of my experience they deem necessary to get the medical attention I may need. Pathways has my permission to speak with paramedics, physicians, therapists, and psychiatrists or psychologists as applicable.
*
Yes
I have read and understand the above questions and by checking this button I certify that my answers are accurate and complete.
*
Yes, I understand the above questions and I certify that my answers are accurate and complete.
Email
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