SCS Matters, LLC

Workshop Application Form

Name as you want it on your certificate:
Name as you want it on your nametag:
Street Address:
City:
State:
Zip Code:
Contact Phone:	( ) -
E-mail Address:
Class, Seminar, or Workshop:	"Please enter the name and date of the class here."
Relevant education and training:	"Please list your relevant education and training here."
Greatest strengths:	"Enter what you consider your greatest strengths here."
Sense of humor:	"How would you describe your sense of humor?"
Learning something new:	"How do you know when you have learned something new? Please provide an example here."
Your wants:	"If you could have anything you wanted as a result of taking this workshop (physical, emotional, mental, and/or spiritual, what would that be?"
Your outcome:	"How would we know when you have achieved your outcome? What would we see and hear that would prove that you have what you want?"
Plans for using knowledge and skills:	"How do you plan to use the knowledge and skills you will gain in the workshop?"
About this program:	"How did you learn about this program?"
*Please check the box at the left to show that you agree with statement that follows. You must* check this box before submitting your registration.** I agree that the information I have supplied above is complete, accurate, and correct to the best of my knowledge. I agree to complete and submit the Workshop Registration form Workshop Registration Form or to call Debra at (269) 921-2217 with the relevant information. I understand that although I may experience significant personal transformation and healing within the context of this training, I understand that the information and exercises are designed for learning purposes and should not be seen as a substitute for appropriate therapeutic intervention. I understand that SCS certification is by license from SCS Matters, LLC, and that only those who have completed Level 5 and are licensed as SCS Trainers are authorized to teach SCS technologies. I understand that certification in Pre- and Postsurgical Support with SCS is by license from SCS Matters, LLC, and that only those who have completed Surgical Support Trainer and are licensed as Pre- and Postsurgical Support with SCS Trainers are authorized to teach Pre- and Postsurgical Support with SCS technologies. I understand that NLP certification is by license from Richard Bandler and NLP Seminars Group International and that to qualify for NLP training I will be required to sign a licensing agreement with Richard Bandler and the Society of Neurolinguistic Programming. I understand that portions of the training may be audio- or videotaped and give my permission for appropriate use of such audio and video recordings.. I understand that all personal information shared as part of the experiential learning is subject to professional privacy laws. I promise to keep personal information shared by others in any SCS class, seminar, or workshop confidential unless otherwise required by law.