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5Peaks Corporate and Organization Form
Please fill out and submit the online form for your Organization.  This form will help me better understand how I can be an asset to your organization/team and create an event that is designed around your culture and goals.  Once we decide on an event structure you will be sent a contract and quote to approve.
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Organization Name *
Contact Name *
Professional Title or Role *
Contact Phone Number *
Contact Email *
What services are you interested in? *
Required
What is your motivation for providing this service to your organization or team?  What goals do you have that you would like to see accomplished? *
What is your organization's mission statement?
How would you describe your corporate/team culture?  What are the strengths and weaknesses? *
How many participants do you anticipate? *
Are you interested in a one-time event or series of sessions? *
Are you looking for a virtual or in-person experience?
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What timeframe/time of year would you like to schedule your event or training?
Will you provide the space for the event?  If so, what is the location/address?  Does it have AV access? *
Is there anything else you would like me to be aware of or bring to my attention in regards to your organization, goals, or event details?
How did you hear of Jennifer Van Rossum/5Peaks? *
DISCLAIMER AND WAIVER OF LIABILITY:  By signing my name below, I expressly acknowledge and agree to all of the following. 1) This program specifically does not offer any therapeutic services and is solely for educational and consultation purposes. 2) While the program may be conducted by a Licensed Professional Counselor, the program is NOT providing any clinical services and does not constitute therapy. 3) No client/patient relationship is created by my attendance in this program. 4) This program is not intended to treat any of the programs' participants. 5) I hereby hold harmless and release, waive, discharge and covenant not sue Jennifer Van Rossum/5Peaks, LLC from any and all claims associated with my participation in the program.  I further expressly agree that the foregoing waiver is intended to be as broad and inclusive as is permitted by the law of the State of Wisconsin. 6) I agree to indemnify and hold Jennifer Van Rossum/5Peaks, LLC harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorneys' fees brought as a result of my involvement in the program. 7) If any portion of the Disclaimer and Waiver of Liability is held invalid, the remaining portions shall, notwithstanding, continue in full legal force and effect. *
I understand that Jennifer Van Rossum, MA, LPC is a mandated reporter and is ethically and legally responsible to report suspected abuse and neglect.
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Electronic Signature of full name *
Today's Date *
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