2010 Portland Training Application & Letter of Commitment

USING SYSTEMIC CONSTELLATIONS IN INDIVIDUAL PRACTICE

I. LETTER OF COMMITMENT

Contact Information:

_________________________________________________________________________________

Payment Options
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.  Send your credit card informaton by registering online at the following secure URL and selecting the event registration that matches your application. Remember to either bring a signed copy of your Letter of Commitment to first day of class, or mail us your application at least a week prior to the start of the Modules for which you are reigstering.

[  ] I am signing up for Module 1 and understand that for this third of the program the tuition is $790.

[  ] I am signing up for Module 1 & 2 and understand that the tuition is $1580.

[  ] I am signing up for all three Modules and understand that the tuition is $2370.

[  ] I have already completed Module 1 & 2 and am signing up for Module 3 only. I understand the tuition is $790.

[  ] I have signed up for multiple Modules and would like to apply for the monthly payment program.

[  ] I am a NCNM or other student in a professional university program, and request the student discount.

NOTE: If you choose the monthly payment plan, please be prepared to provide a credit card number or post-dated checks before 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.

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Agreement

I, ______________________________________ (please print name), hereby signify my commitment to participate in the Facilitator Coaching Course offered by The Human Systems Institute, located in Portland, Oregon, for the 2010 Program-year.

Enclosed is my non-refundable deposit of $195 made out to the Human Systems Institute.  I understand there are three Modules in this course and that certification from the Human Systems Institute will be issued when I successfully complete all three Modules. 

By signing this letter, I am signing up for the Modules I have selected and agree to pay for any sessions I miss during the Modules I have signed up for. 

If I miss a significant portion of a Module or the Course and have paid 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 Course or Module 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 Course, and will do whatever is reasonably within my power to ensure my full participation in the Modules I have elected.

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 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 Course, 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 session, or for refund of moneys covering the balance remaining of the paid Modules if the participant is asked to leave before the Course is completed. 

If a canceled session is rescheduled for that Course-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: (give a brief list or description of your areas of expertise, degrees, trainings, relevant experiences…)

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

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 family and professional systems. 

(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:

FCTP PRO c/o H.S.I.I.

4220 SW Freeman Street

Portland, OR 97219

Or email us.