ICAN Coaching Registration
Type of Coaching Applying For:
Please select...
Individual Coaching
Team/Group Coaching
First Name:
Last Name:
Work Title:
Company Name:
Business Address:
Business City:
Business State:
Business ZIP Code:
Business Phone Number:
Mobile Phone Number:
Business Email Address:
Home Address:
Home City:
Home State:
Home ZIP Code:
Personal Email Address:*
*All correspondence for the program will be sent by email. Please provide an alternate email.
Gender:
Please select...
Female
Male
Non-Binary
Prefer not to answer
Age:
Briefly state what your expectations are in participating in ICAN's Coaching Program:
Have you ever attended an ICAN Program?
Please select...
Yes
No
If so, What ICAN program(s) have you attended?
(Please Select All That Apply)
Women's Leadership Conference
Defining Leadership
Influence / Focus
IMPACT
Women's Leadership Circles
Men's Leadership Exchange
Emergenetics
Learning Bursts
Other
Coach Preference:
Please select...
Female Coach
Male Coach
No Preference
Coaching Style Preference:
Please select...
No Preference
Phone or Zoom Coaching
In-Person or On-Site Coaching
Coaching Topic Interest:
(Please Select All That Apply)
Emotional Intelligence in the Workplace
Work Life Balance
Empowered Communication
Living your Core Values
Discover and Work with your Strengths
Managing & Empowering your Work Team
Developing your Management Style
Managing Stress / What's Draining You? Where do you thrive?
Influential Communication in the Board Room
Creating, Setting and Living your Intentions
I'd like my coach and I to decide together what topic areas to address
Other
Are you interested in purchasing any additional assessments to go along with your coaching session(s)? Please select all that apply.
The LPI® 360
EQ-i 2.0
Emergenetics
Interpersonal Influence Inventory
Ethical Lens Inventory
If You Selected Group Coaching:
Gender Group Preference:
Please select...
Same Gender
Co-Gender
No Preference
Company Group Preference:
Please select...
Group Coaching with Fellow Company Employees
Group Coaching with Other Company Employees
No Preference
If You Selected Individual Coaching:
Number of Sessions:
Please select...
1 session
2 sessions
3 sessions
4 sessions
5 sessions
6 sessions
7 sessions
8 sessions
9 sessions
10 sessions
11 sessions
12 sessions
13 sessions
14 sessions
15 sessions
16 sessions or more
Invoice Contact:
First Name:
Last Name:
Work Title:
Company Name:
Address:
City:
State:
ZIP Code:
Email Address:
Phone Number:
Contact Information