Winner’s Circle Coaches Corner Intake Form Twitter First Name * Last Name * Phone number * Email Address * Address City State – Select Province/State – Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Area of Expertise * Leadership Business Branding and Marketing Finance Health and Fitness Nutrition Faith Mental Wellness Entertainment and Events Nonprofits Relationship Diversity, Equity, and Inclusion Writing and Publishing Social Media Management Personal Development and Self-care Other Your professional title * Biography * Website (if applicable) Social media handles (links preferred) Twitter: Facebook: Instagram: LinkedIn: By Submitting this form, you agree to the following: I will conduct one live workshop, training or coaching session in the Winner’s Circle Community each quarter * Yes No Please provide your Four workshops, trainings, or coaching topics (tittle of message) you will be speaking on. (Please note: the objective of your message must educate, inspire, motivate and/or serve as a valuable resource. You may also update or change a topic at anytime before it is presented) Please provide your Four workshops, trainings, or coaching topics (title of message) you will be speaking on. For each topic, please provide a brief description or learning objective. Topic 1 plus Learning Objective Topic 2 plus Learning Objective Topic 3 plus Learning Objective Topic 4 plus Learning Objective As a WILDE Winner’s Circle Coach, I am committing to my own personal and professional development, and that of my fellow Coaches. I will participate in a Pow Wow with all the Coaches (members may be invited to attend) each quarter. * Yes No I will conduct one live video session in the Winner’s Circle Facebook Community each quarter to (re)introduce myself to the members. * Yes No I will remain an active contributor to the WILDE Winner’s Circle online community, and act as both a conversation starter, and someone who engages in ongoing conversations. * Yes No Profile Picture Please upload a high resolution picture, or email your picture to info@wildeinc.org (will be used for your wilde.org profile and other PR graphics). Formats allowed are: jpg, png, pdf