Group Coaching Annual Plan Sign-Up Form

Terms:

You will save money with your annual membership. Benefits will begin the day you sign up and the annual fee of $1970/yr. will be automatically charged to the credit card account as provided by you, each year on the same date. You may cancel at any time. Please note if a refund is due it will be calculated by subtracting the number of membership months at the current monthly fee from the amount you paid. The refund will occur within 15 days of your written notification of cancellation.

First Name* First Name Required

Last Name* Last Name Required

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City * City is Required

Country * Country is Required

State/Province * State/Province is Required

Zip/Postal Code * Zip/Postal Code is Required

Phone * Phone is Required

Office Name * Office Name is Required

Years in practice? * Years in practice? is Required

What are your top 3 practice challenges, if any? What are your top 3 practice challenges, if any? is not valid

What are your top 3 personal challenges, if any? * What are your top 3 personal challenges, if any? is Required

What results are you wanting from your membership? * What results are you wanting from your membership? is Required

Anything else you would like me to know? Anything else you would like me to know? is not valid

Who may we thank for referring you? Who may we thank for referring you? is not valid

How did you hear about Circle of Success? * How did you hear about Circle of Success? is Required

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Password Strength Password must be "Medium" or stronger

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Dr. Shawn Powers

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Circle of Success - Annual Membership