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Executive Function Coaching - 6 Pack Age 19+
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Contact Information
Applicant First Name:
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Your answer
Applicant Last Name:
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Your answer
Address:
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Your answer
Phone Number:
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Your answer
Email:
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Your answer
Emergency Contact - Name, Relationship, and Number (include cell and work number when relevant):
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Your answer
How did you hear about this service
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Online Search
Word of Mouth
Email
Social Media
Chatterblock
Other:
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Student Profile:
Select appropriate category for EF coaching:
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Post-Secondary
Adult
What are your reasons for enrolling in EF Coaching:
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Your answer
List areas of strength:
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Your answer
Instructional Options:
State lesson format preference:
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In-person sessions
Remote sessions
Desired Start Date:
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MM
/
DD
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YYYY
State preferred days for service:
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Monday
Tuesday
Wednesday
Thursday
Friday
Required
State preferred times:
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Morning
Afternoon
Please provide relevant supporting documentation to complete application:
Psycho-educational assessment
Other:
Clear selection
Personal Consent:
I understand that photos and media (eg. photos) from coaching may be used for marketing purposes and/or be used as a part of our faculty evaluations.
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Agree
Disagree
Payment:
Please select one of the four payment options.
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I will set up automatic credit card payments via
request.plastiq.com/pay-fraser-academy1
(2.4% service fee added)
I will provide post-dated cheques for the desired term
I will pay by Interac e-transfer to the email address
accountspayable@fraseracademy.ca
(no security answer is necessary)
Confirmation:
I understand that the fee for Programs at Fraser Academy is non-refundable, your 6 sessions can be coordinated directly with your instructor with the coach. 24 hours notice is required to reschedule an appointment free of charge.
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Yes
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Signature (type name below)
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