Registration Form

Program Registration Form
PERSONAL INFORMATION
First Name*
Last Name*
Job Title*
Company Name*
Direct Phone Number*
Cell Phone Number*
Email*
Company Address*

CityProvince / State

Postal / Zip CodeCountry
PROGRAM INFORMATION
Which program would you like to register for? *
Greenbelt Program Location*
Lean Agile Program Type*
Whitebelt Program Location*
Blackbelt Program Location*
Executive Program Name*
In-House Program Location*
Program Season*
How will you be paying?*
What is your shirt size?*
What is your jacket size?*
Program Location
What name would you like to appear on your program certificate? *
e.g. John Smith, John A. Smith, John Adam Smith, John A. Smith Jr etc.
Greenbelt Candidates Only - Have you completed the Myers-Briggs Type Indicator (R) (MBTI) personality inventory?*

YesNo
If yes, how long ago did you complete the assessment?*

1-12 months agoMore than 12 months ago
Are you a Lean Sensei Greenbelt or Blackbelt graduate?*

Yes - Greenbelt OnlyYes - Greenbelt and BlackbeltYes - Blackbelt OnlyNo - Other programsNo - Never taken any programs
SPONSOR'S DETAILS
Are you being sponsored to complete this program?*

YesNo
Sponsor's First Name*
Sponsor's Last Name*
Sponsor's Job Title*
Sponsor's Phone Number*
Sponsor's Email*
DIETARY RESTRICTIONS AND HEALTH CONDITIONS
All of our in-person workshops are catered. Do you have any food allergies or restrictions?*

Yes - I have food allergies.Yes - I have dietary restrictions.Yes - I have food allergies AND dietary restrictions.No - I do not have any food allergies or dietary restrictions.
I am allergic to (check all that apply)*

CornEggFishShellfish and crustaceansGarlicMilkMSGPeanutsSesame SeedsSoyOatsSulphitesTree NutsWheat (Celiac Disease)Other
Allergies
I am unable to eat (check all that apply)*

BeefChickenDairyFish / ShellfishGluten (not an allergy)LambMeat (Vegetarian)PorkMeat, Dairy & Egg (Vegan)Other
Restrictions
Do you have any notable health conditions that we should be aware of? (Optional)

NoYes (please specify)
Health Condition Details
PERSONAL EMERGENCY CONTACT DETAILS (Optional)
Personal Emergency Contact Name
Relationship to you
Phone Number
Alternate Phone Number
Email
WORK EMERGENCY CONTACT DETAILS (Optional)
Work Emergency Contact Name
Relationship to you
Phone Number
Alternate Phone Number
Email
TERMS AND CONDITIONS
Terms and Conditions*

I have read and agree to the Lean Sensei International Terms and Conditions
Video and Photo Waiver*

I have read and agree to Lean Sensei International's Video and Photo WaiverI request to opt-out
Release of Contact Information*

I agree to release my contact information to the other class participantsI request to opt-out
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Program Registration Form

PERSONAL INFORMATION

PROGRAM INFORMATION

SPONSOR'S DETAILS

DIETARY RESTRICTIONS AND HEALTH CONDITIONS

PERSONAL EMERGENCY CONTACT DETAILS (Optional)

WORK EMERGENCY CONTACT DETAILS (Optional)

TERMS AND CONDITIONS