Executive Coaching Program—Affiliate Coach Application Form

The information below is needed to be considered for paid coaching assignments through the Support Center’s Executive Coaching Program. You can print out and fax to 212 924 9544 or request a form by email from slevine@supportcenteronline.org

A. Today’s Date:

B. Coach Information

Name:

Company Name (if applicable)

Address

Phone:

Email:

How did you learn about the Support Center’s Coaching Program?

C. Coach Training (Circle and/or write-in your responses to the questions below)

1. Have you attended/are you currently attending a Coach Training Program? Y/N

If so, which Coach Training Program? NYU ICF Other: __________________

If not, do you plan on attending one? Y/N Which One? _____________

2. If you are currently a student, at what stage are you in your training program?

Ind. Study Master Class Certificate Completed Other: __________________

3. Do you currently hold an ICF Credential? Y/N

If so, which ICF credential(s) do you hold? ACC PCC MCC

If so, when did you receive your ICF credential(s)? ______________________________

If not, are you currently working toward an ICF credential? Y/N

When do you anticipate receiving an ICF credential? ___________________________

4. Do you adhere to ICF’s Code of Ethics? Y/N (View ICF’s Code of Ethics Online at: http://www.coachfederation.com/ICF/For+Current+Members/Ethical+Guidelines/)

D. Professional Background/Experience

1. Please describe your background/experience with nonprofit organizations.

2. Please describe your background/experience with executive management.

3. Please describe your background/experience with executive coaching.

4. Please describe your personal coaching style and coaching philosophy.

5. Are you interested in volunteering your coaching services to the Support Center’s Executive Coaching Pro Bono Program? Please explain why or why not.

(Note that pro bono engagements consist of an orientation, 8 weekly sessions of coaching a nonprofit executive director, and 2 feedback sessions.)

6. Are you interested in receiving paid coaching assignments through the Support Center’s Executive Coaching Program? Please explain why or why not.

(Note that while coaching rates may vary, the pay to affiliate coaches rarely exceeds $90 per session.)