Eating Disorder Coach Program Application
Name *
**A payment plan is available. More details are provided in the student contract and on the "FAQ" on the website.
Date of Birth *
Address (Number and street name) *
Address (City, State, Zip Code and Country) *
Email Address *
Phone Number (Home) *
Additional Phone Number (Cell, work, etc.)
Gender *
Profession (Include any professional licenses or certificates) *
Current Employer *
Check All of the Following Avenue(s) of Eating Disorder Coaching You Are Interested In: *
Are you currently involved with any eating disorder organizations? This includes volunteers. *
**If yes to the question above, please list the organization(s) you are involved with, for how long and your role(s).
Have you been trained as a Carolyn Costin Eating Disorder Mentor? *
**If yes to the question above, please answer ALL of the following: (1) Name of organization (2) Date of mentor diploma (3) Dates served as a mentor (4) Please briefly describe your experience:
How did you hear about The Carolyn Costin Institute? *
**If you can provide more specific details about your answer above, we would love to know (i.e. which social media site you saw us on, who specifically referred you, etc.)
Highest Level of Education Completed: If you did not receive a Bachelor's degree or above, you must answer the following question (request for Bachelor's degree waiver) *
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