Coaching for Impact Registration

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About You

First Name

Last Name

Primary Mailing Address

City

State

Zip Code

Primary Address Type

Preferred Email

PersonalWorkOther

Work Email

Personal Email

Other Email

Preferred Phone

MobileWorkHome

Work Phone

Mobile Phone

Home Phone

LinkedIn URL

Date of Birth

Gender

Gender (other)

Race/ethnicity

Race/ethnicity (other)

Where did you learn about Coaching for Impact?

Other

From which blog did you hear about Coaching for Impact?

What is the name of the person who referred you?

Your Work

Current Employer

Current Job Title

Coaching Goals and Your Background

It is important for your coach to understand how you view the world in general and yourself in particular. Please complete the following questions as clearly and thoughtfully as possible. These are “pondering” questions, designed to stimulate your thinking to make your engagement together more productive.

Why do you want to work with a leadership coach? Have you worked with a coach in the past? If yes, how was that experience?

What are 1-2 goals you would like to work on based upon what you know right now? What is holding you back from achieving these goals?

What are you two most effective leadership qualities? What are your two least effective leadership qualities?

What will success look like at the end of your coaching engagement? What will have you accomplished?

What advice do you have for your coach to promote an effective relationship?

What else should we know in order to make this the best match possible?

Coaching Preferences

Each coach has a different coaching style and experience. In order to help us match you, please indicate your preferences below

I prefer a coach with the following industry experience:

I prefer a coach who identifies as:

I prefer a coach who is a person of color

Your Coaching Match

Please let us know your preference on which coaches are your top choices, by considering our Coaching Roster. When making a coaching match we consider your application, the feedback you provided above, those coaches you list here, as well as coach availability.

Please enter the full name of your preferred coaches below:

My preferred coaching match

My second-choice coaching match

My third-choice coaching match

I have no preference – please match me based on my application.

Your Payment

How will your program fee be paid?

My organization / I will submit payment via credit cardMy organization/I would like to be invoicedI am part of custom program that will be invoiced separately (ex. CNA)

Please provide the name and email address of the individual who should received the invoice.

Discount Code

Post-Discount Total

Payment Information

Name on Card

Card Number

Code

Please enter the email address where your registration confirmation should be sent

You have reached the end of the application. By submitting you agree to our Coaching for Impact terms and conditions . Are you ready to submit?

Yes, my application is complete.

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Coaching for Impact Registration