Discover Leadership Training


(All fields in red must be completed)

Participant's Personal Information:
Male Female	First:	Middle:	Last:

Street Address:

Home Phone:

(include area code)

City:

Mobile Phone:

(include area code)

State:

Personal Email:

Zip:

Nominator:

Parent or Guardian Information:

Parent/Guardian's Name:

Employer:

Position:

Street Address:

Phone:

(include area code)

City:

Mobile:

(include area code)

State:

Fax:

Zip:

Email:

Class Information:

Class Type:

Name 3 things, in order of priority, that you would like to gain from this training that will allow you to take your leadership skills to the next level. (ie. self-confidence, focus, etc.)

Class Date:

Class Location:

T-shirt Size:

Medium

Large

X-Large

2X-Large

Are you a graduate of any other Leadership Training Programs?:

No
Yes, specify:

Medical Information:

	Yes	No	Question
1.			Do you have high blood pressure?
2.			Have you ever had high blood pressure?
3.			Are you on any medications for high blood pressure?
4.			To the best of your knowledge are you pregnant?
If you answer YES to any of the follow questions please explain:
5.			Do you have any neck, back, or throat pain/injury? If yes, explain
6.			Do you or have you ever had diabetes, seizures or frequency or unexplained fainting/dizziness? If yes, explain
7.			Do you or have you ever had a heart problem? If yes, explain
8.			Are you currently taking any medication for a heart problem?
9.			Do you or have you ever had counseling or treatment for an emotional, psychological, or mental condition (currently or in the past)? If yes, explain Date of your last treatment
10.			Do you have any special dietary needs? If yes, explain
11.			Do you have any other medical conditions? If yes, explain
12.	What do you do routinely to maintain physical fitness:
13.	Birthdate:
14.	Height:
15.	Weight:

Acknowledgment of Risk and Assumption of Personal Liability and Responsibility

I understand that although Discover Leadership Training has taken precautions to provide proper organization, supervision, instruction, and equipment for each session, it is impossible for Discover Leadership Training to guarantee the absolute safety and well-being for my child. I understand that I share the responsibility for my child’s safety and well-being, and I assume that responsibility.

I have accurately completed the Medical Information section of this form for my child, and have accepted the responsibility to verify with her/his physician, if necessary, that she/he has no physical, psychological, psychiatric, or mental problems that would prohibit her/his participation in Discover Leadership Training’s Cougar Quest camp. I realize that failure to disclose information could result in harm to my child and/or fellow participants, and I agree to indemnify, defend, and hold Discover Leadership Training harmless if all relevant information is not disclosed.

I also acknowledge that if and when my child makes the conscious choice to break a one-inch board during Discover Leadership Training’s Cougar Quest camp, that they have my permission to do so, and I will not hold Discover Leadership Training or any of it’s staff, agents, or volunteers liable for my child’s conscious choice to complete the task of board breaking.

Furthermore, I agree to indemnify, defend, and hold Discover Leadership Training, it’s staff, agents, and volunteers harmless for any threat or injury to my child’s safety or well-being including loss, damages, costs, and expenses, including attorney’s fees, from any such threat or injury to my child’s safety and well-being.

Parent/Gaurdian's Full Name (which will also serve as your signature):

Today's Date:

Tuition Information:

Class Tuition: There is an additional $100 charge for any class that is held at a location other than our Houston and Brookshire training sites.	$1,249.99

Card Type:
Card Number:
Expiration Date:
Name on Credit Card:
Billing Address:
Billing City:
Billing State:
Billing Zip Code:


THERE ARE NO REFUNDS. This agreement may not be cancelled by either party.* Participant agrees to pay the full tuition and fees associated with this enrollment. Full attendance in each session is required. If participant reschedules within 30 days prior to class date, participant will forfeit $500 (except in the event of an unexpected medical emergency, whereby the participant will forfeit $250.00.) Participant MUST re-schedule within one year from date of original workshop, or the remaining balance will be forfeited. In the event that the participant does not show up for the scheduled workshop, participant understands and acknowledges that they will forfeit all tuition and fees associated with this workshop. Participant acknowledges that participant has read and fully understands this agreement before signing. *Class dates are subject to change and/or cancellation. There will be a charge of $50.00 for all returned checks.
Your Full Name (which will serve as your signature):
Today's Date