Individualized Session
Application Form

Complete this form and press submit to register! We will contact you upon receipt of your form to confirm your reservation or give your further instructions.

  • NAME:
  • ADDRESS:
  • CITY:
  • STATE/PROVINCE:
  • ZIP/POST CODE:
  • COUNTRY:
  • PHONE:
  • FAX:
  • E-MAIL:

PAYMENT INFORMATION

We accept Visa, MasterCard,
American Express and Discover.

  • NAME ON CARD:
  • CARD NUMBER:
  • EXP DATE:

BACKGROUND AND PREFERENCES

MY PURPOSE FOR WANTING TO ATTEND THIS SESSION IS:

I WISH TO ATTEND:

  • A SESSION ALONE
  • A SESSION WITH ONE OTHER
  • A SESSION WITH TWO OTHERS

PLEASE GIVE DETAILS IF YOU HAVE
ALREADY ARRANGED TO ATTEND WITH OTHERS:

MY PREFERENCES FOR THE DATES ARE:

  • FIRST CHOICE
  • SECOND CHOICE
  • THIRD CHOICE

MY MEAL CHOICES ARE:

  • VEGETARIAN
  • MEAT
  • POULTRY
  • VEGAN
  • FISH ONLY
  • FISH OR POULTRY

BREAKFAST SELECTIONS:

  • CEREALS
  • OATMEAL
  • WAFFLES
  • EGGS
  • BACON, SAUSAGE, HAM
  • TOAST, ENG. MUFFINS

PLEASE DETAIL YOUR FAVORITE BREAKFASTS AND YOUR FAVORITE BREADS, CEREALS, AND MEATS:

  • FRUIT
  • YOGURT
  • COCOA
  • COFFEE
  • DECAF. COFFEE
  • TEA
  • JUICE

PLEASE DETAIL YOUR FAVORITE FRUITS, YOGURTS, JUICES, AND OTHER DRINKS

WHAT LUNCHEON FOODS DO YOU LIKE THE MOST (PLEASE BE SPECIFIC):

WHAT FOODS DO YOU NOT EAT (PLEASE BE SPECIFIC)?



Copyright © 2011-2017 Athena Leadership Center. All rights reserved.   |  Web Development