WILGA Balanced Life Specialist Application Form

BALANCED LIFE SPECIALIST CERTIFICATION

APPLICATION FORM
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Date of Birth

MonthDayYear
Date
Gender
Marital Status
No. of children and their ages, if any
Languages you speak and write fluently in
Religious or spiritual affinity (optional)
Organizational affiliations, memberships in clubs, etc.
Volunteer activities and social service
Employment Status
Employer Classification, if employed
TELL US SOMETHING ABOUT YOU
Do you have experience in any of the following? Please check all that apply.

EntrepreneurshipBusiness managementLeadership rolesCoachingMentoringPublic speakingWorkshop facilitationTraining
Please provide any relevant information about your work experience particularly in relation to coaching and/or training and facilitation
What are your hobbies and talents?
What are your greatest strengths?
What are your greatest weaknesses?
Tell us about a challenging moment in your life and how you overcame it
Tell us about any experience of meaningful success or achievement in your life
Who have been your role models, teachers, mentors or people who have influenced you in your life? How did they influence you?
Please share any experience of working in and/or leading a team/(s). What were some of the successes or challenges you faced in a team setting?
What is your life's ambition/purpose?
How did you find out about this program?
Why do you want to join this program?
What do you hope to achieve from this program?
TELL US ABOUT YOUR OVER-ALL HEALTH AND HABITS
Do you consume?

TeaCoffeeAlcoholPrescription drugsRecreational drugs
Please provide more information about any medication or drugs that you are using
My diet is mainly
Please describe your exercise routine including frequency
What is your weight goal?
Your Physical Health Status. Please check all conditions that apply.

HypertensionLow Blood PressureHeart DiseaseAsthmaDiabetesAnemiaInternal Organ IssuesSpinal IssuesCancerAddictionLearning DisabilitiesEpilepsyVertigoMigraineReproductive IssuesPainFatigueSleep IssuesAccelerated Aging
Please specify any major health issues that you currently have or have experienced in the past

Please rate your over-all health

	Poor	Fair	Good	Very Good	Excellent
Physical Health
Vitality and Energy Level
Emotional Stability
Mental Attitude and Clarity
Religious/Spiritual/Inner Alignment

Please rate your general quality of life

	Poor	Fair	Good	Very Good	Excellent
Relationships at Home
Relationships at Work
Social Relationships
Job/Role Satisfaction
Quality of Rest/Relaxation
Ability to Manage Stress
Quality and Time for Recreation
Financial/Material Life
Level of Success
Level of Self-Fulfillment in Life

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DISCLAIMER/WAIVER

I understand that the Wisdom Institute for Leadership and Global Advancement (WILGA) and the WILGA Balanced Life Specialist Certification Programs application is private and confidential and all my information will not be shared with any third parties.

I certify that everything I have written and answered is true and correct to the best of my knowledge.
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Date of Application

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BALANCED LIFE SPECIALIST CERTIFICATION