CCP Application 2020

Name*

First Middle Last

Preferred Name

What is your gender?

Female
Male
Non-binary/third gender
Prefer not to say

Title / Position

Upload Your Bio*

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

Address*

City Country

Phone (primary)*

Phone (mobile)

Email*

Please ensure your email address is entered correctly.

Company / Organization

Company / Organization Website

Education / Degree (check only highest level attained)*

Please estimate your total years of coaching:*

Have you completed a three-day Minds at Work Facilitator’s Workshop or a five-week ITC Mapmaking for 1:1 Coaching Workshop?*

Yes
No

Please provide the year you attended the three-day Minds at Work Facilitator’s Workshop or five-week Immunity to Change™ Mapmaking for 1:1 Coaching Workshop.

Please confirm your understanding that 1) either the three-day Facilitator's Workshop or or the five-week ITC Mapmaking for 1:1 Coaching Workshop (as determined by Minds at Work) is a required prerequisite for participation in the Coach Certification program, 2) that the Workshop must be completed prior to the first residency and 3) that the Workshop will require a fee in addition to the Coach Certification Program tuition.*

Yes, I understand.

We will discuss the prerequisite with you further prior to or during your interview. We have direct-entry spaces available in the September 23-25, 2020 Online Facilitator's Workshop. We recommend you hold these dates.

Attendance at a Facilitator Workshop is a prerequisite for admission to the Coach Certification Program. Any exceptions will be made on a case-by-case basis.

Proficiency in spoken and written English is essential for participation in the Coach Certification Program.*

I affirm that I am proficient in spoken and written English.

If not English, in what language do you anticipate you will be using with the majority of your prospective Immunity to Change™ clients?

Please specify the language you'll use (if other)*

How did you learn about this program?

Immunity to Change™ Facilitator's Workshop
Immunity to Change™ Book
Session by Minds at Work Faculty
Mindsatwork.com website
A coach or other helping professional
A colleague/friend/family member

What function best describes your position?*

Please specify

Please check your primary field/industry:*

Provide a brief description of your organization:*

Please describe your current responsibilities:*

What factor has most influenced your decision to apply to this program? Why does the Immunity to Change™ Coach Certification Program appeal to you at this point in your career? How do you envision using Immunity to Change™?*

Please explain your objectives and goals as they relate to attending this program. Also describe what you think other program participants may learn from you (e.g. perspectives, skills, expertise):*

Who are your primary coaching clients (individuals, teams, level in organization, etc.)?*

Do you have an adaptive (not technical) personal Improvement Goal that is of high interest and importance to you? This may or may not be related to your being an even more effective coach / change practitioner. Most important is that the goal is important to you!*

Do you have a potential “practice client” in mind that could be a case study for your learning during the program? (The practice client is not a paying client.)*

Yes
No

Please check below if you:

Are applying with multiple people from the same organization.
Work exclusively in the non-profit sector.

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Please fill out the form below to apply for our Coach Certification Program.