The MythoSelf Weekend Experience Application

Application Form

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Country

Home Phone*
Home Phone*

E-mail Address

Web Site URL

Business Phone

Profession*
Profession*

Previous Personal Development training*
Previous Personal Development training*

	No
	Yes

If "yes" what training(s) have you taken?

What is your reason for attending the program with Mark Schwimmer and Dennis Charles, and what specifically do you want to get from joining this program?*
What is your reason for attending the program with Mark Schwimmer and Dennis Charles, and what specifically do you want to get from joining this program?*

Have you ever done work with, or studied with Mark Schwimmer or Dennis Charles or the MythoSelf Process in the past? *
Have you ever done work with, or studied with Mark Schwimmer or Dennis Charles or the MythoSelf Process in the past? *

	No
	Yes

If "Yes" what are the circumstances (e.g. MythoSelf program, private work with Dennis or Mark or another MythoSelf facilitator or trainer-whom, when and where?)*
If "Yes" what are the circumstances (e.g. MythoSelf program, private work with Dennis or Mark or another MythoSelf facilitator or trainer-whom, when and where?)*

Are you mentally, emotionally, and physically up for this program?

	No
	Yes

Do you understand that this program is an eductional program only, and no claims are made for treatment of any kind-mental, emotional, or physical?*
Do you understand that this program is an eductional program only, and no claims are made for treatment of any kind-mental, emotional, or physical?*

	No
	Yes

Are you under the care of a physician for any mental, emotional or physical condition or reason that would impair your ability to participate in this program?*
Are you under the care of a physician for any mental, emotional or physical condition or reason that would impair your ability to participate in this program?*

	No
	Yes

Are you at least 18 years old?*
Are you at least 18 years old?*

	No
	Yes

Are you ready to participate in a program that may change your current beliefs and way of being and operating in the world?*
Are you ready to participate in a program that may change your current beliefs and way of being and operating in the world?*

	No
	Yes

Do you understand that this program represents the learning of Mark Schwimmer , Dennis Charles, and Jeffrey Leiken as taught by Dr. Joseph Riggio in regard to the MythoSelf Model only as indicated in the program description, and no other claims than this are implied?*
Do you understand that this program represents the learning of Mark Schwimmer , Dennis Charles, and Jeffrey Leiken as taught by Dr. Joseph Riggio in regard to the MythoSelf Model only as indicated in the program description, and no other claims than this are implied?*

	No
	Yes

Are you prepared to use the material presented in this program in an ethical and moral manner that supports your own sense of integrity?*
Are you prepared to use the material presented in this program in an ethical and moral manner that supports your own sense of integrity?*

	No
	Yes

Do you have a sense of humor, a sense of curiousity, a sense of wonder and eagerness and desire to learn even more?*
Do you have a sense of humor, a sense of curiousity, a sense of wonder and eagerness and desire to learn even more?*

	No
	Yes

Are you willing and able to take the next steps in your personal evolution?*
Are you willing and able to take the next steps in your personal evolution?*

	No
	Yes

Have you read the entire application, understand and agree to all the terms and conditions within as they are stated?*
Have you read the entire application, understand and agree to all the terms and conditions within as they are stated?*

	No
	Yes

Based on the information and your answers to these questions are you prepared to commit yourself to being a participant in this training program and contribuying to your own education and the simultaneous education of others?*
Based on the information and your answers to these questions are you prepared to commit yourself to being a participant in this training program and contribuying to your own education and the simultaneous education of others?*

	No
	Yes

You have already taken the first step. If you answered yes to the previous question then choose your payment option in the following area fill in your payment information, and submit.*
You have already taken the first step. If you answered yes to the previous question then choose your payment option in the following area fill in your payment information, and submit.*

How do you choose to pay?*
How do you choose to pay?*

Name on Credit Card

Credit Card Number

expiration date (mm/yy)

CCV

Please enter the word that you see below.

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