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2022 Adult Intake & Consent Forms for SDA (ages 25+)

You must submit Forms before purchase to complete enrollment and registration.

-Consent Forms

-Policies and Procedures Agreement Form

Please fill out, read, and submit.

Don't be overwhelmed by the field tally. Each "field" is one piece of information such as "name" or "age." These forms are easy to complete.

These forms can time out and cause an error; therefore, please do not click "start" until you are ready to complete, and allow yourself enough time to finish in one sitting - approximately 15-20 minutes.

This is a one-time per year form submission.  If you have already submitted this form for this year for yourself and anyone else you are responsible for, you are complete.

Failure to submit Forms will result in losing access to the membership portal.

Click the button below to start.

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2022 Intake & Consent Forms for SDA - Adult (25+)

SUBMISSION GUIDELINES

 FOR

RELEASE FORM

AND

HOLD HARMLESS FORM

 

Please make sure all involved parties submit this form.  It is part of registering for Success Dynamics Academy.  Failure to complete promptly will result in denied access.

 

These documents must be submitted each year by the following:

Students 18 and older

The Party Responsible for Payment

 

Please make sure all involved parties submit these forms.

 

All SDA Students 18 and older submit these forms.  However, if the Student and the Party Responsible are NOT the same person, then a separate form must be submitted by both parties.

 

Personal Information

Your Information is never shared or sold!

 

Correct contact information is vital.  It is used here primarily for communicating about Success Dynamics Academy:  questions, curriculum, coaching announcements, and reminders.  Please include the SDA Student's contact information to ensure communication is open, up to date, and helps everyone arrive at coaching calls and sessions on time.

 

STEPS TO COMPLETE THIS FORM

 

The intake system has some limitations, and therefore, you will see fields that need a duplicate answer.  In these cases, please write out the correct answer again, instead of "same as above" type answers.

Some fields may not apply to you, but you will need to read and answer those, too (write N/A in those.)

 

Please fill out all fields correctly to complete the Form.

 

Unfortunately, the intake system does not currently have a "back" button; however, you can review your answers after submission and resubmit if you have missed or misspelled any information.

 

The SDA Intake & Consent Forms are not complete unless you check all the boxes, including both the boxes under each Form, signifying you have read and agree to both the Release & Hold Harmless Forms.

 

I appreciate your patience!

 

 

Question 3 of 30

Your Email:

Question 4 of 30

Your Name:

Question 5 of 30

Email used on SDA profile:

Question 6 of 30

Please state, using the exact phrases written in bold, the position that describes you best:

 

The Client - Party Responsible for Payment (You or your spouse pays for enrollment.)

 

The Client - Not Responsible for Payment (This answer typically applies when the student's enrollment is paid for by a parent/guardian).

 

The Parent/Guardian - Party Responsible for Payment

 

Party Responsible for Payment - Not Guardian (This answer typically applies if another relative, a friend, or clergy is paying for the student's enrollment.)

 

After reading through the descriptions above, the position that describes me best is:

Question 7 of 30

If you answered "Party Responsible for Payment - Not Guardian" on the question above - you are NOT the student's parent, but you ARE responsible for payment, please state your relationship to the SDA student:  (*Put N/A if this doesn't apply.)

Question 8 of 30

SDA Student's Name:

Question 9 of 30

SDA Student's Age:

Question 10 of 30

SDA Student's Date of Birth (mm/dd/yyyy):

Question 11 of 30

SDA Student's Email:

Question 12 of 30

SDA Student's Mobile Phone:

Question 13 of 30

Name of Party Responsible for Payment:

Question 14 of 30

Email of Party Responsible for Payment:  (please list the email that is attached to the SDA payment here.)

Question 15 of 30

Mobile Phone of Party Responsible for Payment:

Success Dynamic Academy Policies & Procedures Agreement

FOR SDA ADULT MEMBERSHIPS AGES 18+

Question 17 of 30

Private Use Only:

 

Success Dynamics Academy (SDA) is for private use only.  SDA membership is not a certification program for participants to become a coach, instructor, or energy psychology practitioner.  Participants are prohibited from teaching or sharing any information, training, coaching, or other content from the Success Dynamics Academy.

 

(Select all that apply)
A

I understand that my membership in Success Dynamics Academy is for private use only

B

I understand that my participation in SDA does not serve as a certification in any discipline.

C

I understand that any information I learn in SDA is for my own consumption and not to be taught or shared with others.

Question 18 of 30

SDA Online Training Procedure:

 

Success Dynamics Academy (SDA) curriculum has many training sessions.  The new curriculum is delivered over time (every 4-8 weeks) into an online portal and is available on specific days and times.

 

Success Dynamics Academy membership is for individual adults age 18+.  Therefore, each person listening to SDA should have purchased it and submitted the proper forms.

 

Clients have access to SDA until they cancel their subscription.

 

Clients may listen and review the curriculum through the online portal anytime.

 

Recording or downloading any of the SDA recordings is not permitted.

 

Copying, sharing, or otherwise distributing the SDA curriculum or any of its content is not permitted. 

 

(Select all that apply)
A

I understand that my SDA curriculum training sessions will be made available to me over time. Each training will open in the online portal on specific days and times.

B

I understand that viewing the training should be done through the online portal only. I agree not to record or download any recordings from the portal.

C

I understand that SDA adult memberships (18+) are individual memberships. I agree not to share any training or worksheets with those who have not purchased the program.

Question 19 of 30

Cancellation Policy:

 

Sometimes people are tempted to cancel their subscription.  Please be very conscious that the nature of Inner Work can sometimes challenge you to follow through.  Often, the times you want to cancel are the very times you need to continue forward and remove the block in your way.

 

You may cancel any time before the next billing cycle within your PayPal account.

 

You may also email us with a cancellation request.  Please email at least a week before your next billing cycle to allow time for the cancellation request to process.  Send requests to:

 

 [email protected] 

 

  • There is a seven day money back guarantee.  After this time period, there are no refunds on any current or prior month.  When you enroll, you have immediate access to several training lessons all with the accompanying worksheets, so you can begin increasing your self-coaching ability immediately.
  • If you cancel you lose access to the Success Dynamics Academy Library and any included bonuses.
  • If you choose to re-enroll, your membership will restart from the beginning training, not pick up where you left.

 

 

(Select all that apply)
A

I understand I have 7 days from the time of purchase to cancel and receive refund; however, I will lose access to the Success Dynamics Academy Library and all included bonuses.

B

I understand I can cancel my membership any time before the next billing cycle within my PayPal account.

C

I understand I can make a cancellation request via email but will need to give at least a week's notice before my next billing cycle to allow processing time and avoid another payment.

D

I understand that if I choose to cancel my membership and re-enroll, my membership does not pick up where I left off but starts me back at the beginning.

Question 20 of 30

Type your name as it would appear on a Signed Document:

Release Form

For Success Dynamics Academy- Adult (Aged 25+)

Question 22 of 30

 

 

I, _________, understand that nothing said, done, performed, typed, printed, or produced by Peggy Nazer is intended or meant to diagnose, prescribe, treat a disease or take the place of diagnoses by a licensed physician, psychologist, or psychiatrist.

 

Consultations by phone or email, training, coursework, coaching sessions, energy psychology work sessions, Integrative Processing Technique (IPT) sessions, integration sessions, classes, or techniques are to promote healthy lifestyles and cultivate the mind/body connection.

 

A variety of non-invasive methods, modalities, and programs, commonly referred to as Energy Psychology, may be used, which include but are not limited to, bio-kinesiology (muscle response testing-MRT). MRT is used to determine past events and identify negative emotions stored in certain chakras or energy centers of the body.  Guided imagery, NLP, speaking out feelings, role-playing, inner child work, chakra work, visualization and various Energy Psychology techniques are used.  The purpose of using these techniques is to bring the client to a place of inner healing/reconciling and a strong sense of well-being and closure with the issues being addressed.

 

This form is a release form granting Peggy Nazer permission to release and clear negative energy and process my family member or me through experiences using both conscious awareness and energy release techniques.  This authorization is valid for any and all private and group sessions as well as any coursework involving Peggy Nazer.

 

(Select all that apply)
A

I agree that these Terms and Conditions apply to and for any adult children for whom I am paying for Peggy Nazer's services.

B

I have read and agree to these Terms and Conditions. I understand that submitting this form serves as my electronic signature

Question 23 of 30

Type your name as it would appear on a Signed Document:

Hold Harmless Form

For Success Dynamics Academy - Adult (Aged 25+)

Question 25 of 30

 

 

In consideration of receiving life coaching & energy psychology work from Peggy Nazer (DBA Peggy Nazer Coaching), I hereby release, waive and discharge all rights to legal action against and covenant not to sue, and agree to forever hold harmless for any and all purposes, Peggy Nazer Coaching from any and all liabilities, claims and/or demands that may result from coaching and/or energy psychology work, provided by Peggy Nazer Coaching.

 

My election to receive coaching & energy psychology work or any other services provided by Peggy Nazer Coaching is completely voluntary and at my own discretion.  I also hereby acknowledge that Peggy Nazer Coaching does not make any promises or guarantees that her methods will help or cure me of any type of condition or health problem. I voluntarily assume full responsibility for any risks or outcomes that may result from receiving coaching or energy psychology work, whether caused by commission or omission on the part of Peggy Nazer Coaching.

 

It is my expressed intent that this Covenant Not To Sue and Hold Harmless Agreement shall bind the members of my family, spouse, heirs, and their families and personal representatives.  I acknowledge and represent that I have read the foregoing Covenant and Agreement, understand it, and voluntarily agree to it, and its terms in full as my own free act and deed; no oral representations, statements, or inducements apart from the foregoing agreement that has been reduced to writing have been made.  I execute this document as full, adequate, and complete, fully intending to be bound by the same, now and in the future.

 

(Select all that apply)
A

I agree that these Terms and Conditions apply to and for any adult children for whom I am paying for Peggy Nazer's services.

B

I have read and agree to this Covenant and Agreement. I understand that submitting this form serves as my electronic signature

Question 26 of 30

Type your name as it would appear on a Signed Document:

Question 27 of 30

Please state, using the exact phrases written in bold, the position that describes you best:

 

The Client - Party Responsible for Payment (You or your spouse pays for enrollment.)

 

The Client - Not Responsible for Payment (This answer typically applies when the student's enrollment is paid for by a parent/guardian.)

 

The Parent/Guardian - Party Responsible for Payment

 

Party Responsible for Payment - Not Guardian (This answer typically applies if another relative, a friend, or clergy is paying for the student's enrollment.)

 

After reading through the descriptions above, the position that describes me best is:

Question 28 of 30

Completed Intake Forms are required from the SDA student AND the Party Responsible for Payment of Services.  Submit separate forms if these parties are not the same person.

A

I understand that both Intake Forms must be submitted by the SDA student AND the party responsible for payment. Failure to fill out all fields and submit both forms by all parties involved will result in denied access to the SDA portal until all necessary forms are complete and submitted. The SDA subscription will not be refunded or prorated due to denied access.

Question 29 of 30

Another limitation of this form's platform is that there is no "back" button; however, after submitting this document, you will be able to see your results.  Please review all personal information to make sure it is correct and complete.  If you missed or misspelled anything, please correct it and resubmit.  Your missing or inaccurate information can result in your withdrawal from enrollment without a refund.

 

(Select all that apply)
A

I understand that all information on this form must be correct and complete.

B

I understand that missing or inaccurate information can result in being withdrawn from enrollment without a refund.

C

I understand that I can review my information on the forms after submitting them. I can resubmit corrected forms if necessary.

Question 30 of 30

Your Name as it would appear on a signed document:

Confirm and Submit