The Gestalt Institute of Cleveland

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Application for Gestalt Institute of Cleveland Coaching Certification Program

Six months - 4 modules- starting November 11, 2009.

Solution GraphicsNotes:

  1. 1. Additional information may be required.
  2. 2. We accept MasterCard, Visa, Discover, and American Express
  3. 3. Notify the Registrar (registrar@gestaltcleveland.org) about any problems
  4. 4. For programs, the date listed is the start date only. See program description for all dates
  5. 5. Mail this form with check if you cannot pay by credit card, to:

    Gestalt Institute of Cleveland
    1588 Hazel Drive
    Cleveland, OH 44106

Program Application Fee - $150 (non refundable)

Please select your preferred payment plan:

Early Bird (10% discount) - $7704.00 (No other discounts apply.)
Full Tuition - $8560.00 if paid in full prior to program start.
Full Tuition - $8635.00 on payment plan.


The fees below include a $75.00 administrative charge spread over the three payments.

  • $4305.00 before the program begins
  • $2165.00 before the second 5 day session
  • $2165.00 before the third 5 day session


Personal Information
First Name
Last Name
Credential
Address  
Click if new address:
 
City
State/Province
Zip/Postal Code
Country

Home Phone
Work Phone
Fax
Email
Organization Information
Present Position
Business/Organization
How long have you been there?
Address
 
City
State/Province
Zip/Postal Code
Country
Responsibilities
Education
Highest Education Other
Coaching Experience
Do you have coaching experience? Yes No
How long have you been coaching?
How many clients
do you coach in a year?
If you currently coach,
please enter the percentage of time
spent in each of the following areas
(Should total 100%)		 Life Coaching
Executive Coaching
Business Coaching
Leadership Coaching
Career Coaching
Health Coaching
Spiritual Coaching
Other Coaching
What training programs and/or
workshops have you completed at
Gestalt Institute of Cleveland (GIC)?
Please list the titles and
date of completion.
What Gestalt Workshops/Programs have you completed from an organization other than GIC? Please list the titles, date of completion
and organization.
Do you have ICF Certification? No
ACC
PCC
MCC
What workshops/programs have you attended that incorporated ICF core competencies? Please list the titles and dates of completion.
Why are you attending the program? What do you hope to get out of it?
References
- Reference 1  
Name
Address
City
State/Province
Zip/Postal Code
Country
Phone
Fax
Email
- Reference 2  
Name
Address
City
State/Province
Zip/Postal Code
Country
Phone
Fax
Email


Refunds Refunds are available up to 21 days prior to a workshop, less a $75 administration fee.
Notice of
 Nondiscriminatory
 Policy		 The Gestalt Institute of Cleveland admits participants of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at GIC. It does not discriminate on the basis of race, color, national or ethnic origin, gender, sexual orientation, or handicapped condition in administration of its educational policies, admissions policies, scholarship and loan programs, and other GICadministered programs.
Mail Registrar
Gestalt Institute of Cleveland
1588 Hazel Drive
Cleveland, OH 44106-1791
Phone (216) 421-0468
Fax (216) 421-1729
Email registrar@gestaltcleveland.org  
Additional application information may be required.
What would be your prefered format for receiving any requests?
Email   Fax   Mail

Receipt of application does not guarantee acceptance into a workshop until notified. Please wait until notified before making travel and other arrangements.