To be completed by potential program partners seeking to participate in the Outpatient Coaching Program or in other CoachArt programs.

Company Name:
Contact Name:
Address:
City:
State:
Zip Code:
Daytime Phone #:
Mobile #:
E-mail:

I am interested in becoming a coach for:

	Outpatient Coaching Program (10 lessons, 10 weeks, individual or small group)
	Program Events (special events, field trips or wokshops)

My Company/Organization Teaches:
My Company/Organization is Located:
Is there insurance for that space? Yes      No
Do you provide background checks on your employees? Yes      No
I would like a CoachArt staff member to come speak with my employees. Yes      No
I plan to attend the following Volunteer Orientation:

Tuesday, July 18, 2006	7:00 - 8:30pm
Tuesday, August 22, 2006	7:00 - 8:30pm
Tuesday, September 19, 2006	7:00 - 8:30pm
Tuesday, October 17, 2006	7:00 - 8:30pm
Tuesday, November 28, 2006	7:00 - 8:30pm
Tuesday, December 12, 2006	7:00 - 8:30pm

 

All orientations take place at 1999 Avenue of the Stars, SunAmerica Building (corner of Avenue of the Stars & Constellation Boulevard) Los Angeles, CA 90067 Bear Stearns Conference Room, 32nd Floor