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    <input name="inf_form_name" type="hidden" value="Updated SCU Enrollment Application" />
    <input name="infusionsoft_version" type="hidden" value="1.29.11.21" />
    <div class="infusion-field">
        <label for="inf_field_FirstName">First Name *</label>
        <input class="infusion-field-input-container" id="inf_field_FirstName" name="inf_field_FirstName" type="text" />
    </div>
    <div class="infusion-field">
        <label for="inf_field_LastName">Last Name *</label>
        <input class="infusion-field-input-container" id="inf_field_LastName" name="inf_field_LastName" type="text" />
    </div>
    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_SexCoachLevel1" name="inf_option_SexCoachLevel1" type="checkbox" value="997" />
            <label for="inf_option_SexCoachLevel1">Sex Coach/Level 1</label>
        </span>
    </div>
    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_SexExpertLevel2" name="inf_option_SexExpertLevel2" type="checkbox" value="999" />
            <label for="inf_option_SexExpertLevel2">Sex Expert/Level 2</label>
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    </div>
    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_SexCoachTrainerLevel3" name="inf_option_SexCoachTrainerLevel3" type="checkbox" value="1001" />
            <label for="inf_option_SexCoachTrainerLevel3">Sex Coach Trainer/Level 3</label>
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    <div class="infusion-field">
        <label for="inf_custom_Haveyouhaveenrolledincoursesinsexcoachtrainingbefore">Have you have enrolled in courses in sex coach training before? *</label>
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                <input id="inf_custom_Haveyouhaveenrolledincoursesinsexcoachtrainingbefore_Yes" name="inf_custom_Haveyouhaveenrolledincoursesinsexcoachtrainingbefore" type="radio" value="Yes" />
                <label for="inf_custom_Haveyouhaveenrolledincoursesinsexcoachtrainingbefore_Yes">Yes</label>
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                <input id="inf_custom_Haveyouhaveenrolledincoursesinsexcoachtrainingbefore_No" name="inf_custom_Haveyouhaveenrolledincoursesinsexcoachtrainingbefore" type="radio" value="No" />
                <label for="inf_custom_Haveyouhaveenrolledincoursesinsexcoachtrainingbefore_No">No</label>
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        <label for="inf_custom_Salutation">Salutation *</label>
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                <input id="inf_custom_Salutation_Mr." name="inf_custom_Salutation" type="radio" value="Mr." />
                <label for="inf_custom_Salutation_Mr.">Mr.</label>
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                <input id="inf_custom_Salutation_Mrs." name="inf_custom_Salutation" type="radio" value="Mrs." />
                <label for="inf_custom_Salutation_Mrs.">Mrs.</label>
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                <input id="inf_custom_Salutation_Ms." name="inf_custom_Salutation" type="radio" value="Ms." />
                <label for="inf_custom_Salutation_Ms.">Ms.</label>
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                <input id="inf_custom_Salutation_Dr." name="inf_custom_Salutation" type="radio" value="Dr." />
                <label for="inf_custom_Salutation_Dr.">Dr.</label>
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                <input id="inf_custom_Salutation_Other" name="inf_custom_Salutation" type="radio" value="Other" />
                <label for="inf_custom_Salutation_Other">Other</label>
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        <label for="inf_field_StreetAddress1">Street Address *</label>
        <input class="infusion-field-input-container" id="inf_field_StreetAddress1" name="inf_field_StreetAddress1" type="text" />
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    <div class="infusion-field">
        <label for="inf_field_StreetAddress2">Street Address 2</label>
        <input class="infusion-field-input-container" id="inf_field_StreetAddress2" name="inf_field_StreetAddress2" type="text" />
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    <div class="infusion-field">
        <label for="inf_field_City">City *</label>
        <input class="infusion-field-input-container" id="inf_field_City" name="inf_field_City" type="text" />
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    <div class="infusion-field">
        <label for="inf_field_State">State/Province/Region *</label>
        <input class="infusion-field-input-container" id="inf_field_State" name="inf_field_State" type="text" />
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    <div class="infusion-field">
        <label for="inf_field_PostalCode">Postal / Zip Code *</label>
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        <label for="inf_field_Phone1">Phone Number *</label>
        <input class="infusion-field-input-container" id="inf_field_Phone1" name="inf_field_Phone1" type="text" />
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    <div class="infusion-field">
        <label for="inf_field_Email">Email *</label>
        <input class="infusion-field-input-container" id="inf_field_Email" name="inf_field_Email" type="text" />
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    <div class="infusion-field">
        <label for="inf_custom_SkypeID">Skype Name</label>
        <input class="infusion-field-input-container" id="inf_custom_SkypeID" name="inf_custom_SkypeID" type="text" />
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    <div class="infusion-field">
        <label for="inf_custom_EmergencyContactInformation">Emergency Contact  *</label>
        <textarea cols="24" id="inf_custom_EmergencyContactInformation" name="inf_custom_EmergencyContactInformation" rows="5">
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    <div class="infusion-field">
        <label for="inf_custom_EmergencyContactPhoneNumber">Emergency Contact Phone Number *</label>
        <input class="infusion-field-input-container" id="inf_custom_EmergencyContactPhoneNumber" name="inf_custom_EmergencyContactPhoneNumber" type="text" />
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    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_Internetsearch" name="inf_option_Internetsearch" type="checkbox" value="1017" />
            <label for="inf_option_Internetsearch">Internet search</label>
        </span>
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    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_Referredbycolleagueorfriend" name="inf_option_Referredbycolleagueorfriend" type="checkbox" value="1019" />
            <label for="inf_option_Referredbycolleagueorfriend">Referred by colleague or friend</label>
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    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_Newsmediaorothermediaoutlets" name="inf_option_Newsmediaorothermediaoutlets" type="checkbox" value="1023" />
            <label for="inf_option_Newsmediaorothermediaoutlets">News media or other media outlets</label>
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    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_DrRobertswebsites" name="inf_option_DrRobertswebsites" type="checkbox" value="1025" />
            <label for="inf_option_DrRobertswebsites">Dr. Robert's website(s)</label>
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    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_ReferralfromanSCUstudent" name="inf_option_ReferralfromanSCUstudent" type="checkbox" value="1027" />
            <label for="inf_option_ReferralfromanSCUstudent">Referral from an SCU student</label>
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    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_FacebookPageforSCU" name="inf_option_FacebookPageforSCU" type="checkbox" value="1029" />
            <label for="inf_option_FacebookPageforSCU">Facebook Page for SCU</label>
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    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_DrPattiswebsite" name="inf_option_DrPattiswebsite" type="checkbox" value="1031" />
            <label for="inf_option_DrPattiswebsite">Dr. Patti's website</label>
        </span>
    </div>
    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_ReadDrPattisbookTheArtofSexCoaching" name="inf_option_ReadDrPattisbookTheArtofSexCoaching" type="checkbox" value="1033" />
            <label for="inf_option_ReadDrPattisbookTheArtofSexCoaching">Read Dr. Patti's book: The Art of Sex Coaching</label>
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    </div>
    <div class="infusion-field">
        <label for="inf_custom_Highesteducationcompleted0">Highest education completed: *</label>
        <div class="infusion-radio">
            <span class="infusion-option">
                <input id="inf_custom_Highesteducationcompleted0_GED/HS" name="inf_custom_Highesteducationcompleted0" type="radio" value="GED/HS" />
                <label for="inf_custom_Highesteducationcompleted0_GED/HS">GED/HS</label>
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            <span class="infusion-option">
                <input id="inf_custom_Highesteducationcompleted0_AA or some college" name="inf_custom_Highesteducationcompleted0" type="radio" value="AA or some college" />
                <label for="inf_custom_Highesteducationcompleted0_AA or some college">AA or some college</label>
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            <span class="infusion-option">
                <input id="inf_custom_Highesteducationcompleted0_Technical School" name="inf_custom_Highesteducationcompleted0" type="radio" value="Technical School" />
                <label for="inf_custom_Highesteducationcompleted0_Technical School">Technical School</label>
            </span>
            <span class="infusion-option">
                <input id="inf_custom_Highesteducationcompleted0_Bachelors Degree" name="inf_custom_Highesteducationcompleted0" type="radio" value="Bachelors Degree" />
                <label for="inf_custom_Highesteducationcompleted0_Bachelors Degree">Bachelors Degree</label>
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            <span class="infusion-option">
                <input id="inf_custom_Highesteducationcompleted0_Masters Degree" name="inf_custom_Highesteducationcompleted0" type="radio" value="Masters Degree" />
                <label for="inf_custom_Highesteducationcompleted0_Masters Degree">Masters Degree</label>
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        </div>
    </div>
    <div class="infusion-field">
        <label for="inf_custom_CollegeDegreeType">If you have earned a college or advanced degree, or have other professional certifications, indicate the content areas or types of certifications in the space below *</label>
        <textarea cols="24" id="inf_custom_CollegeDegreeType" name="inf_custom_CollegeDegreeType" rows="5">
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    <div class="infusion-field">
        <label for="inf_custom_LevelofcomputerskillsandeaseonInternet">Level of computer skills and ease on Internet: (check your level below) *</label>
        <div class="infusion-radio">
            <span class="infusion-option">
                <input id="inf_custom_LevelofcomputerskillsandeaseonInternet_Low" name="inf_custom_LevelofcomputerskillsandeaseonInternet" type="radio" value="Low" />
                <label for="inf_custom_LevelofcomputerskillsandeaseonInternet_Low">Low</label>
            </span>
            <span class="infusion-option">
                <input id="inf_custom_LevelofcomputerskillsandeaseonInternet_Moderate" name="inf_custom_LevelofcomputerskillsandeaseonInternet" type="radio" value="Moderate" />
                <label for="inf_custom_LevelofcomputerskillsandeaseonInternet_Moderate">Moderate</label>
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            <span class="infusion-option">
                <input id="inf_custom_LevelofcomputerskillsandeaseonInternet_High" name="inf_custom_LevelofcomputerskillsandeaseonInternet" type="radio" value="High" />
                <label for="inf_custom_LevelofcomputerskillsandeaseonInternet_High">High</label>
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        </div>
    </div>
    <div class="infusion-field">
        <label for="inf_custom_Relationshipstatus0">Relationship status:</label>
        <div class="infusion-radio">
            <span class="infusion-option">
                <input id="inf_custom_Relationshipstatus0_Single" name="inf_custom_Relationshipstatus0" type="radio" value="Single" />
                <label for="inf_custom_Relationshipstatus0_Single">Single</label>
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            <span class="infusion-option">
                <input id="inf_custom_Relationshipstatus0_Married" name="inf_custom_Relationshipstatus0" type="radio" value="Married" />
                <label for="inf_custom_Relationshipstatus0_Married">Married</label>
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            <span class="infusion-option">
                <input id="inf_custom_Relationshipstatus0_Living with Partner" name="inf_custom_Relationshipstatus0" type="radio" value="Living with Partner" />
                <label for="inf_custom_Relationshipstatus0_Living with Partner">Living with Partner</label>
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            <span class="infusion-option">
                <input id="inf_custom_Relationshipstatus0_Divorced" name="inf_custom_Relationshipstatus0" type="radio" value="Divorced" />
                <label for="inf_custom_Relationshipstatus0_Divorced">Divorced</label>
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            <span class="infusion-option">
                <input id="inf_custom_Relationshipstatus0_Seperated" name="inf_custom_Relationshipstatus0" type="radio" value="Seperated" />
                <label for="inf_custom_Relationshipstatus0_Seperated">Seperated</label>
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            <span class="infusion-option">
                <input id="inf_custom_Relationshipstatus0_Other" name="inf_custom_Relationshipstatus0" type="radio" value="Other" />
                <label for="inf_custom_Relationshipstatus0_Other">Other</label>
            </span>
        </div>
    </div>
    <div class="infusion-field">
        <label for="inf_custom_OtherPertinentInformation">Other Pertinent Information: (Example: learning disability, difficulties with concentration, physical limitations, etc.)</label>
        <textarea cols="24" id="inf_custom_OtherPertinentInformation" name="inf_custom_OtherPertinentInformation" rows="5">
    </textarea></div>
    <div class="infusion-field">
        <label for="inf_custom_ProfessionalBackground">Your Professional Background: A listing of your professional accomplishments to date: (Example: You brought busines into financial success, are a well known tantric master, earned a degree in marketing, won public speaking award, started a successful home party company, or whatever you think is relevant for us to know) *</label>
        <textarea cols="24" id="inf_custom_ProfessionalBackground" name="inf_custom_ProfessionalBackground" rows="5">
    </textarea></div>
    <div class="infusion-field">
        <label for="inf_custom_AcademicOrIndependentStudyPreparation">A Statement Of Academic Or Independent Study Preparation: *</label>
        <textarea cols="24" id="inf_custom_AcademicOrIndependentStudyPreparation" name="inf_custom_AcademicOrIndependentStudyPreparation" rows="5">
    </textarea></div>
    <div class="infusion-field">
        <label for="inf_custom_YourGoalsIntentionsAndDreams">A Statement of Your Goals, Intentions And Dreams: Why do you want to enroll in Sex Coach U? *</label>
        <textarea cols="24" id="inf_custom_YourGoalsIntentionsAndDreams" name="inf_custom_YourGoalsIntentionsAndDreams" rows="5">
    </textarea></div>
    <div class="infusion-field">
        <label for="inf_custom_Abilitytoselfdirectandretainselfmotivation">A Statement About Your Ability To Self-Direct A Retain Self-Motivation For Online Learning: *</label>
        <textarea cols="24" id="inf_custom_Abilitytoselfdirectandretainselfmotivation" name="inf_custom_Abilitytoselfdirectandretainselfmotivation" rows="5">
    </textarea></div>
    <div class="infusion-field">
        <label for="inf_custom_WhatItMeansToYouToBecomeASexCoach">A Personal Statement About What It Means To You To Become A Sex Coach: *</label>
        <textarea cols="24" id="inf_custom_WhatItMeansToYouToBecomeASexCoach" name="inf_custom_WhatItMeansToYouToBecomeASexCoach" rows="5">
    </textarea></div>
    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_Haveyoueverbeenarrestedconvictedofacriminalactorbeenincarcerated" name="inf_option_Haveyoueverbeenarrestedconvictedofacriminalactorbeenincarcerated" type="checkbox" value="1039" />
            <label for="inf_option_Haveyoueverbeenarrestedconvictedofacriminalactorbeenincarcerated">Have you ever been arrested, convicted of a criminal act, or been incarcerated?</label>
        </span>
    </div>
    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_Haveyoueverbeeninvolvedinalawsuit" name="inf_option_Haveyoueverbeeninvolvedinalawsuit" type="checkbox" value="1041" />
            <label for="inf_option_Haveyoueverbeeninvolvedinalawsuit">Have you ever been involved in a lawsuit?</label>
        </span>
    </div>
    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_Haveyoueverbeeninstitutionalizedforamentaldisorderorbeeninanongoingoutpatientprogramforamentalhealthcondition" name="inf_option_Haveyoueverbeeninstitutionalizedforamentaldisorderorbeeninanongoingoutpatientprogramforamentalhealthcondition" type="checkbox" value="1043" />
            <label for="inf_option_Haveyoueverbeeninstitutionalizedforamentaldisorderorbeeninanongoingoutpatientprogramforamentalhealthcondition">Have you ever been institutionalized for a mental disorder or been in an ongoing outpatient program for a mental health condition?</label>
        </span>
    </div>
    <div class="infusion-field">
        <label for="inf_custom_1AcademicIndependentStudyAbilityReference">1) Academic/Independent Study Ability Reference: (name/email/tele#/Skype)</label>
        <textarea cols="24" id="inf_custom_1AcademicIndependentStudyAbilityReference" name="inf_custom_1AcademicIndependentStudyAbilityReference" rows="5">
    </textarea></div>
    <div class="infusion-field">
        <label for="inf_custom_PersonalCharacterReference">2) Personal Character Reference: (name/email/tele#/Skype) *</label>
        <textarea cols="24" id="inf_custom_PersonalCharacterReference" name="inf_custom_PersonalCharacterReference" rows="5">
    </textarea></div>
    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_IamfullypreparedtobringmyverybestselfbothprofessionallyandpersonallytobecometrainedandcertifiedthroughSEXCOACHU" name="inf_option_IamfullypreparedtobringmyverybestselfbothprofessionallyandpersonallytobecometrainedandcertifiedthroughSEXCOACHU" type="checkbox" value="1045" />
            <label for="inf_option_IamfullypreparedtobringmyverybestselfbothprofessionallyandpersonallytobecometrainedandcertifiedthroughSEXCOACHU"> I am fully prepared to bring my very best self, both professionally and personally, to become trained and certified through SEX COACH U. </label>
        </span>
    </div>
    <div class="infusion-field">
        <span class="infusion-option">
            <input id="inf_option_Agree" name="inf_option_Agree" type="checkbox" value="1047" />
            <label for="inf_option_Agree">Agree</label>
        </span>
    </div>
    <div class="infusion-submit">
        <input type="submit" value="Submit" />
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</form>

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