2008 Portland Training

Application & Letter of Commitment

Facilitating Constellations in Professional Practice

USING SYSTEMIC CONSTELLATIONS IN INDIVIDUAL PRACTICE

I. LETTER OF COMMITMENT

Please either:

a) If paying by check, print and mail the completed form to us at the address given at the end of the document, or

b) If paying by credit card, copy this form into Word, complete and send as email attachment.  Remember to bring a signed copy of your Letter of Commitment to first day of class.

[  ] I am signing up for this Program with the goal of certification and future listing on the H.S.I., Inc.® web-site.

[  ] I am signing up for this Program and am not interested in certification.

I, ______________________________________ (please print name), hereby signify my commitment to participate in the Facilitator Coaching Program offered by The Human Systems Institute, located in Portland, Oregon, for the Program-year 2008-9.

Enclosed is my non-refundable deposit of $375 made out to the Human Systems Institute.  There are five in-class sessions in the course of this Program.  There are three payment options are available.  I am selecting (mark one):

[  ] Early registration (MUST BE RECEIVED BY SEPT. 30, 2008) of $1695. (Balance due after $375 deposit is $1320.)

[  ]  Single payment (due first day of class) of $1875.  (Balance due after $375 deposit is $1500.)

[  ] Monthly payment of $385 each due the first day of class each month. Students may pay off the remaining balance due at any time during the course of Program. 

NOTE: If you choose the monthly plan, please be prepared to provide a credit card number or post-dated checks at the beginning of the first session.  If you provide a credit card number you will be charged the Thursday before the first day of class each session.  Post-dated checks are held in our safe-deposit box until the week before the session when they will be cashed.  We can be flexible on check dates if needed.

By signing this letter, I am signing up for the entire Program and agree to pay for any sessions I miss.  I understand I have until seven days after the last day of the first session to withdraw from the program.  I agree to notify the Institute either by phone to 503-293-0017 or in writing.  (No emails please.)  At which point I owe only $385 for the first session, and all other funds I may have paid will be returned to me.  By continuing in the Program after that date, I agree to pay the full Program tuition. 

If I miss a significant portion of the Program and pay my tuition, with the director’s permission, I may return in the following year, should this program be offered again, and complete the missed portions of the Program without any additional tuition charges, providing space is available.  Failure to pay tuition payments on time may result in my being removed from the program.  I understand my participation is important to the success of the other members of the Program, and will do whatever is reasonably within my power to ensure my full participation in the Program.

The Human Systems Institute, Inc.®, Jane Peterson, Donald Chitwood, their trainers and assistants, reserve the right to accept or reject any person as a participant at any time, and to make changes in the Program or setting whenever deemed necessary for the comfort, convenience and safety of the participants, and to cancel a Program session at any time.

In the rare event a session must be canceled and cannot be rescheduled or a participant is asked to leave during a Program-year, the Human Systems Institute, Inc.®, Jane Peterson or Donald Chitwood or any trainers or assistants supporting the institute shall have no responsibility beyond the refund of moneys paid to it by participants for the canceled Program session, or for refund of moneys covering the balance remaining of the Program if the participant is asked to leave. 

If a canceled session is rescheduled for that Program-year, and I chose not to attend, it is up to me to make up the session in a following year providing space is available, and the Human Systems Institute, Inc.® is not responsible for refunding my tuition for that session. 

By signing, I agree that neither The Human Systems Institute, Inc.®, Jane Peterson, Donald Chitwood nor any other person acting at the request and on behalf of the institute shall be liable for any damages, loss or expense occasioned by any act or omission by themselves, their assigns, or any other Program participant.

Signature_____________________________________

Print Name____________________________________

Dated_________________

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II. APPLICATION FORM

Full name:

Best phone number to reach you at:

Best email to reach you at:

Professional information

1. Please describe your current profession:

2. Number of years in this profession:

3. Please give us a brief biography of your professional and other important personal milestones:

Background in this field

1. Please describe your involvement with constellation work up to this point, specifically, who have you seen facilitate, how many constellations have you observed or participated in, what other trainings have you participated in?  Please especially tell us how many constellations you personally may have done, if any, on your own personal issues and, very briefly, what the topics were.

2. Please describe any reading, videos or other study of constellation work you have done on your own or in study groups:

3. Please describe any other relevant experience you have as a practitioner.

Learning Goals

1. My primary learning goals are:

[  ] I would like to incorporate Hellinger’s Systemic Constellation concepts in my profession in the following ways:

[  ] I am participating in this program for my own personal evolution with the understanding that this is designed as a professional development program.

2. What I want from this program is:

(a) Professionally:

(b) Personally:

3. What I bring to this program is: (give a brief list or description of your areas of expertise, degrees, trainings, relevant experiences…)

4. What would be especially helpful in coaching me is: (or what I would appreciate is)….

5.  Optional section.  Since this training addresses family systems work, it is helpful to the trainer to understand something of your lived experience in your own families. 

(Circle what applies)

Marital Status

I am currently:  married  / divorced / single (never married)  / remarried / not married, living with partner          

other______________________

Children

I have ____ biological children of ages:

I have ____ step-children of ages:

I have ____ adopted children of ages:

I have no children

Other comments you would like the trainers to know about your current family situation or family of origin?

6. Anything else you would like us to know?

Mail to:

iFCTP c/o The Human Systems Institute

4220 SW Freeman Street

Portland, OR 97219

Or email us.