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Mastery Application

Welcome to Mastery I. We are delighted that you have made this the next step on your continuing journey.

We ask that you begin the process by taking some time to fill out this application and return it to C3 Training.
Once registered, you will receive your pre-program materials to support your preparation for Mastery I.

Methods of Payment accepted:

Cash, Cheques, Money orders, Amex, Paypal, ,

We are please to offer the following 3 methods to register for our courses:

1. Print out this registration form and mail or fax to the address below:

Mailing Address: C3 Training
#302, 200 Dougall Road N
Kelowna, BC
V1X 3K5

Fax: 250-491-9662

2. Phone 1-800-630-5575 for more information

3. Fill in the online registration form below and it will be emailed to our office. We will contact you to confirm your registration and arrange for payment.

We are pleased to offer our clients the option to pay for the course registration online through PayPal!

Name of your Context Representative:

Full Name:

Name you would like to be called:

Address:

City:

State/Province:

Zip/Postal code:

Home phone (with area code):

Work phone (with area code):

Fax (with area code):

Email address:

Gender:

male female

Marital status:

Age(s) of children:

Occupation:

Position:

Employer:

Last year of formal education completed:

Other classes you’ve attended in the past two years (personal or professional):

Last C3 Training or Context Associated course I attended (if any):

Course Name:
Course Date:

1. What is your purpose for attending Mastery 1?

2. Which areas of your life would you like to enhance while attending this Course? (mark all that apply)

Career

Outlook on life

Communication skills

Relationships

Physical well-being

Family

Finances

Productivity

Self-confidence

Other (please specify):

3. Who (other than yourself) most influenced your decision to attend Mastery?

**PARTICIPANT HEALTH INFORMATION

Context Associated/C3 Training courses are for everyone who wants to and is prepared to move ahead in life with more clarity. As a result of attending this course, people generally feel better about themselves and their lives. During each course, time is spent in self-exploration, such as examining attitudes and behaviors which may limit success. These courses, however, are not therapy and are not conducted in a therapeutic setting. They are solely experiential and educational programs, and are not designed or recommended for people experiencing serious emotional or mental difficulties.

To ensure that the staff may more effectively accommodate your needs while you are in this program, the following information is requested: (This information will be kept confidential and is for staff use only.)

1. Do you have any medical conditions or disabilities that may require special accommodations while in this program?

YES NO

If so, please describe below:

2. Is there anything else about your physical condition such as epilepsy, asthma, diabetes, heart problems, etc., which could be a problem for you while you are in this program?

YES NO

If so, please describe below

3. Do you have any mental health issues that might influence your participation or the participation of others during this training?

a. Have you ever or do you now suffer from depressive, anxiety/panic or other serious mental health disorders?

YES NO

b. Are you suicidal now or have you ever attempted suicide?

YES NO

c. Have you ever assaulted another person?

YES NO

d. Do you or others consider you to be a violent person?

YES NO

e. Have you been hospitalized for psychiatric reasons within the past five years?

YES NO

Please describe below anything else that we need to know that is not addressed in the above parts of question 3.

4. Are you currently taking any prescription or over-the-counter medications for any of the above physical or mental health conditions?

YES NO

If so, please describe below.

5. For Residential Programs, please indicate any special needs you have regarding diet, allergies and general well being while attending the course.

Describe:

Please carefully consider the following:

1. If you have a medical condition that requires special treatment throughout the day, please do not attend this program until you consult your health professional.

2. C3Training is not a mental health service provider. Do not take this seminar if you are having serious emotional problems or are having difficulty coping with your life.

3. If you are currently in treatment for psychological issues please do not attend this seminar until you have consulted with your treatment provider.

The person to be contacted in the event of an emergency is:

Name:

Relationship:

Address:

Home Phone (with area code):

Work Phone (with area code):

Cell Phone (with area code):

I hereby acknowledge that I have read thoroughly and carefully the above information and that I understand it. I have carefully considered and have answered all questions candidly.

Please mark check the appropriate box:

Agree Disagree

Date:

I. Acknowledgments and Representations

I understand that I will not be fully informed about the content of C3 Training course I am about to take. I understand and acknowledge that the course is designed as an experience and that any benefits I receive from it will come through my own discovery and initiative.

I understand and acknowledge that I may experience uncomfortable emotions as a result of taking the course. I assume all risk of such consequences and I agree that my sole remedy is limited to the refund of my course tuition, and nothing else.

I understand that the course is neither psychotherapy nor medical therapy, nor is it a substitute for these services. I understand that course leaders are not licensed psychiatrists or psychologists. I do not expect the course to be administered with the standard of therapeutic care I would expect from trained mental health professionals.

I acknowledge that if I have mental or emotional problems I should not take this course. If I have concerns about my mental or emotional health, I have consulted a psychiatrist, psychologist or other mental health professional and that professional has approved my participation in the course.

I do not have physical problems or deficiencies that would prevent me from fully participating in the course schedule. If I have any doubts about my physical ability to participate according to the published schedule, I have consulted with my physician and that physician has approved my participation in the course.

If I have concerns about my mental or physical well being or my level of stress during any course session I promise to notify the course leader immediately. I understand that I am free to leave the course at any time, for any reason. If I feel the need for assistance from anyone, professional or otherwise, I take full personal responsibility for immediately leaving the course and obtaining it.

I understand that C3 Training will provide Context Associated, the publisher of course materials, with the names of participants.

I understand that C3 Training is relying upon the truth and accuracy of the above acknowledgments and representations.

II. Indemnity and Release & Arbitration

I accept personal responsibility for my participation in C3 Training courses. For myself and on behalf of my heirs, representatives, successors and assigns, I agree that, except arising from gross negligence or willful misconduct, I shall release C3 Training and its officers, agents, employees, course participants and representatives, and their successors and assigns, from any claim for loss, damage or injury.

I agree to indemnify and hold C3 Training, its officers, agents, employees, course participants and representatives, and their successors and assigns, harmless from all injury, damage, claims, liabilities, costs and expenses (i) arising from or related to my participation in any of the company’s courses, or (ii) related to any of my acknowledgments or representations in this Agreement being untrue.

I certify that I am 18 years or older, that I have read this document carefully, and that I understand and agree with its contents.

Please choose the appropriate box: Agree Disagree

Date: