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Registrant Information

First name

Last name

Common name

Birthday (format: mm-dd-yyyy)

Phone number

Mobile number

Home Phone (emergency use only):

Business name

Type of business

Credit Card

We only accept Visa, Mastercard and American Express

Billing Address

First Name

Last Name

Street address

Unit / Apt / Suite

City

Country

State / Province / Region

Zip / Postal code

Shipping Address

Same as Billing Address

Street address

Unit / Apt / Suite

City

Country

State / Province / Region

Zip / Postal code

Additional Information

Is there someone specific that referred you to us? If so, please provide their name(s):

Please list any professional/trade associations to which you belong, if any.

Name of Assistant or Key Administrative Staff:

Email Address (Assistant)

Phone/Extension (Assistant)

Please inform us in advance of any specific dietary needs you may have:

Income Verification

I certify that my personal income from entrepreneurial activities is:
$500,000 to $1,000,000
More than $1 Million

By signing up as a Strategic Coach® client, you certify that you have read and agreed to Strategic Coach’s Privacy Policy and Terms and Conditions, and you understand that your acceptance and participation in the Strategic Coach® Program is dependent upon a Right-Fit conversation with a Membership Advisor and verification of your qualifying entrepreneurial income level. You also understand that:

the balance of your annual fee is due three weeks prior to the date of the first session, and if you register for the Program within three weeks of the first session, the full annual fee amount is due at the time of registration; and
your deposit is non-refundable or transferable; and
once you attend the first session, none of the annual fee is refundable or transferable, and there is no credit for missed sessions; and
Strategic Coach may contact me, electronically or otherwise, regarding my progress in the Program or to let me know about new products, services, and features offered by Strategic Coach.

Authorization for charging the deposit

I hereby authorize The Strategic Coach Inc./The Strategic Coach USA Inc. to charge the credit card account number on this form for the deposit amount of USD $2,500.

I authorize The Strategic Coach Inc./The Strategic Coach USA Inc. to charge the balance on the full investment amount three weeks prior to the start date using the above credit card.

I agree to the Terms & Conditions.