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The Nine Month Self Mastery Program 
October 2006-June 2007
Student Application
First Name
Last Name
Street Address1
Street Address2
City
State
Zip Code
Day Phone
Evening Phone
eMail Address
Date of Birth
I am interested in taking this program:
for personal growth for expanding my professional skills Both
Please note your highest academic training level:
Please list additional personal growth training you’ve experienced:
Are you actively practicing a spiritual path at this time?
Are you currently in therapy?   Yes  No
Under the care of a psychiatrist?   Yes  No
Using a medicine for mental health and balance?   Yes   No
Which one?
What are your passions? 
What do you consider to be your greatest strength?
What do you consider to be your greatest weakness or challenge?
Are you already aware of specific forgiveness issues you want to work on?
What gifts do you bring to a group learning situation?
What concerns do you need addressed in order to be comfortable in a group? 
Do you have other thoughts about why this program is just right for you now?
How did you hear about this program?