Coaching Registration Form
Speech Coaching
              
  Name:
  *E-mail:
  Telephone:
     
Type of Coaching Desired (check one):  

   One-on-one
   Telephone  
   Email
   Video/DVD
  Area of Coaching Desired (check one): 

   Public Speaking  
   Voice  
   Performance

  
       
  (In 90 words or less) 
Indicate your priorities in the area you are seeking to improve:
   
  (In 90 words or less) 
Currently, what are your major obstacles to achieving your goals in the area you indicate above?
  
       
  Payment Form

Payment can be submitted online via secure credit card (MasterCard or Visa only) 
or by printing this form, completing it, and sending it via fax or by mail. Checks 
and money orders drawn on financial institutions within the USA are also welcome.
   
  Card Number 
  Expiration date of card  (month/year)
  Name (as it appears on credit card) 
  Billing address of credit card:
 
Security Code 
(last three numbers on back of credit card) 
  

Once this form has been completed, 
print the form and
fax to: 717-728-2296
or mail to: P.O. Box 405, Enola, PA 17025

      
 

Please make checks and money orders payable to Dr. Dilip R. Abayasekara
Mailing address: P.O. Box 405, Enola, PA 17025, USA
Fax Number: (717) 728-2296 Telephone: (717) 728-2203 Email: drdilip@centralpenn.com