Eating Disorder Coach Program Application
THE APPLICATION PROCESS CONSISTS OF TWO STEPS:
STEP 1: The written application (this)

STEP 2: A video submission (instructions will be provided after the written application is submitted)

**Applications are not reviewed until both the written and video submissions are received**
PROGRAM COST $4850
**A payment plan is available. More details are provided in the student contract and on the "FAQ" on the website.
Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address (Number and street name) *
Your answer
Address (City, State, Zip Code and Country) *
Your answer
Email Address *
Your answer
Phone Number (Home) *
Your answer
Additional Phone Number (Cell, work, etc.)
Your answer
Gender *
Profession (Include any professional licenses or certificates) *
Your answer
Current Employer *
Your answer
Check All of the Following Avenue(s) of Eating Disorder Coaching You Are Interested In: *
Required
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).
Your answer
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:
Your answer
How did you hear about The Carolyn Costin Institute? *
Required
**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.)
Your answer
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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