Registration Form - Choice in Life [November 2016]
First name *
Your answer
Last name *
Your answer
Name that you want to be called in the training *
Please note that this will be the name appearing on your name tag
Your answer
Country *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Phone number *
Regular and mobile number
Your answer
Email *
Please provide a valid e-mail address as it will be used for further communication with you
Your answer
Do you need a visa in order to travel to the Netherlands? *
Contact person in case of emergency *
Full name, address, phone number, relationship to you
Your answer
Diet *
Level of English *
Occupation status *
You can select more than one options.
Required
In which Event Wise (Basic Synergy) Training did you participate and when? *
In case you participated or assisted in more trainings within the Synergy Group, please specify.
Your answer
In which Choice Training did you participate and when? *
In case you participated or assisted in more trainings within the Synergy Group, please specify.
Your answer
I am doing the Choice in Life training for the following reasons: *
Your answer
I declare that I will have a medical insurance valid in the Netherlands for the duration of the training. *
Required
Other remarks or questions
Your answer
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