Basic Registration

Step #1: Choose Your In-Person Basic Class:*
I am a...*
In-Person Tuition
$150 Basic Deposit (Deposit)
$795 Basic Adult (Full Payment)
$495 Basic Young Adult (Full Payment)
$495 Repeat (Full Payment)
$0 Repeat Young Adult attending with new student
$0 Repeat Adult with attending new student
Tuition Option*

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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*
The email address used must belong to the student listed above. Please do not use a shared email address.
Why do you want to attend the Basic 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
Additional Children
- I have more than 3 kids
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
Additional Children (more than 6)
- I have more than 6 kids
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
Who will be attending with you?
First Last
For Minor's Guardian Only
Minor's Name
First Last
Full Name of Parent or Guardian
First Last
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 Basic Course. I further certify that all of the responses in the minor's Basic 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
Signature
Name
Date

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Payment Information
Discount Code
Total
$0.00
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.
Terms & Conditions
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.
Signature
Name*
Date*
Refund Policy
The Basic Course has been created for people who desire to get more out of their life. It is of value only if you are totally involved. For those few individuals who do not benefit from the Course, we offer the following guarantee: "If you are not satisfied with the Basic Course, we will refund your tuition completely." In order to qualify for the refund, you must: 1. Attend the entire three (3) or four (4) day Basic Course; 2. Submit a written request for a refund. The request must be received by the Pathways Chicago office no later than 5 PM CST ten (10) days from the last day of the course. The Facilitator may terminate the participation of any participant whose conduct is disruptive or inconsistent with the purposes of the Course. Said participant would be eligible for a partial refund (tuition minus non-refundable deposit) to be paid no later than ten (10) days following the receipt of the refund request.
Refund policy acknowledgement*
- I acknowledge that I have read, understand and agree to all of the above terms and conditions of the Refund Policy.
Signature
Name*
Date*

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Step 1 of 6

In-Person Tuition

Personal Details

Business Details

Family Details

Who shared the course with you? (Sponsor)

Emergency Contacts

Repeating Students Only

For Minor's Guardian Only

Minor Guardian Waiver

Payment Information

Terms & Conditions

Refund Policy

Medical and Psychological Information