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Coach Certification ApplicationNote: For renewals, please see "Coach Recertification Application".Dear Wellcoaches Certification Candidate:Thank you for your interest in attaining an ACSM-endorsed Wellcoaches coach certification and your contribution tothe Wellcoaches community.This application has been designed to support you in effectively attaining your Health Coach, Wellness Coach and/orFitness Coach certification.Certification fees must be paid, and all exams completed successfully, prior to submitting this application.The certification follows ACSM certification guidelines and is progressing toward meeting NCCA certificationguidelines:1.2.3.4.Three-hour written exam (scheduled at www.pearsonvue.com/acsm)30-minute telephone practical skills assessment.Submission of practice client sessions (wellness vision, 3-month goals and 4 sessions worth of weekly goals)Verification of prerequisites.Your application and associated documentation will not be returned. Please make a copy of yourapplication and supporting documents before submitting your application package. While it is importantthat you fully document your experiences, do not over document. Do not include books or extraneousmaterials and please do not bind your application.NOTE: Certification does not include access to the Wellcoaches Web Coaching Platform. For access you are invited tobecome a Coach-in Practice Member – click here to register.If you have any questions about this application or related issues please contact your Coach Concierge who hasbeen assigned according to the first initial of your last name as follows:A - G: Julie Cummings at jcummings@wellcoaches.com or 866-932-6224 ext. 712H - O: Angela Miller Barton at amillerbarton@wellcoaches.com or 866-932-6224 ext. 715P - Z: Sheryl Richard at srichard@wellcoaches.com or 866-932-6224 ext. 713Best regards,The Wellcoaches TeamCoachCertApp 2011Page 1 of 7Updated: 05/01/2011

Coach Certification ApplicationNote: For renewals, please see "Coach Recertification Application".Coach Certification Application Checklist1. KEEP A COPY OF YOUR APPLICATION, AND ANY ATTACHMENTS, FOR YOUR OWN FILE.2.INCLUDE A COPY OF YOUR TRANSCRIPT. (IF APPLICABLE – BOTH OFFICIAL AND UNOFFICIAL TRANSCRIPTS WILL BEACCEPTED.)3.PLEASE ALLOW UP TO 30 DAYS FOR APPLICATION PROCESSING.4.YOU WILL RECEIVE AN E-MAIL CONFIRMATION FROM WELLCOACHES CORPORATION THAT YOUR APPLICATIONHAS BEEN RECEIVED. IF YOU HAVE NOT RECEIVED CONFIRMATION WITHIN 30 DAYS, PLEASE CONTACT YOURCOACH CONCIERGE WHO HAS BEEN ASSIGNED ACCORDING TO THE FIRST I NITIAL OF YOUR LAST NAME ASFOLLOWS:A - G: Julie Cummings at jcummings@wellcoaches.com or 866-932-6224 ext. 712H - O: Angela Miller Barton at amillerbarton@wellcoaches.com or 866-932-6224 ext. 715P - Z: Sheryl Richard at srichard@wellcoaches.com or 866-932-6224 ext. 7135.DELIVERY OPTIONS:a.b.c.Email to your Coach ConciergeToll Free Fax: 1-888-893-8481Mail to: Wellcoaches Corporation, 19 Weston Road, Wellesley, MA 02482(If sending by mail please allow up to 60 days for processing.)CoachCertApp 2011Page 2 of 7Updated: 05/01/2011

Coach Certification ApplicationNote: For renewals, please see "Coach Recertification Application".Wellcoaches Certified Coach ApplicationThis application must be completed in its entirety according to the directions contained in the application. The normalprocessing time, provided all materials are included with the application is 30 days from submission. If you have notbeen notified by Wellcoaches Corporation of your application review result within 30 days of submission pleasecontact your Coach Concierge.Instructions: Fill out all sections, include the appropriate attachments, read and sign or initial where requested, andeither: Email to your Coach ConciergeSubmit via Toll Free Fax: 1-888-893-8481Mail to: Wellcoaches Corporation, 19 Weston Road, Wellesley, MA 02482 (If sending by mail, please allow up to60 days for processing.)Note: Upon successful completion of the new Health Coach and Wellness Coach Training Program launched in January2009, all trainees with nurse/clinical backgrounds (e.g. registered nurses, registered dietitians and other licensedhealth professionals] will be eligible to receive both a Wellness Coach Certification and a Health Coach Certification. Ifqualifying Fitness Coach prerequisite(s) are also held the candidate may also receive Fitness Coach Certification. Allcertifications will be covered under the one certification fee of 495.00.Are you eligible to receive a Health Coach and/or Fitness Coach Certification [see pages 6-7] YES NOIf yes, please indicate which Certification(s) you are applying for: Wellness Coach Health Coach Fitness CoachApplicant InformationName (as you would like it to appear on your certificate):Birth Date (required):Mailing Address:Preferred Email:Phone:Fax:Date of Application:CoachCertApp 2011Page 3 of 7Updated: 05/01/2011

Coach Certification ApplicationNote: For renewals, please see "Coach Recertification Application".Statements of Agreement and ComplianceI, acknowledge that my signature below attests that I understand and certify that the following statements are trueand correct:1.As the applicant, it is my responsibility to communicate and validate my qualifications to clearly show that Imeet or exceed each of the requirements appropriate for the certification(s) for which I am applying.2.I have no adverse legal actions taken or pending against me as a coach or my coaching business.3.I release any individual from any previous bond of confidentiality, whether explicit or implied, for thepurpose of validating my qualifications for a Wellcoaches Corporation awarded certification.4.I acknowledge that the Certified Coach designations (CWC, CHC, CFC) are valid for a three (3) year period. Inorder to renew a certification, one must successfully complete a minimum of 30 hours of ContinuingCoaching Education (CCE), and document 45 hours of client coaching within that three (3) year period oftime.5.I agree that Wellcoaches Corporation may change or modify the rules governing certification at any time andhas the power to revoke any individual certification for violation of those rules.6.I will abide by the decision/recommendations of the Application Review.7.I give permission for Wellcoaches Corporation to verify my experience and documentation. I understand thatWellcoaches Corporation will keep all information confidential.8.I agree to honor the rules and regulations of Wellcoaches Corporation’s certification process. I further agreethat Wellcoaches Corporation has sole discretion to issue or amend the rules and regulations governing thecertification program at any time or revoke certification and I agree to abide by any decision of WellcoachesCorporation regarding the matters of certification.Applicant signatureDateCoachCertApp 2011Page 4 of 7Updated: 05/01/2011

Coach Certification ApplicationNote: For renewals, please see "Coach Recertification Application".Attachment 1: Verification of PrerequisitesWellness Coach Certification Prerequisite: Please submit a copy of evidence of one of the following prerequisites(including state licenses where appropriate). Prerequisite MUST be 18.Associates degree or higher, in exercise, nutrition, nursing, health psychology, or a related health field (see listbelow)Masters degree in a mental health or health field (e.g. social work, counseling or clinical psychology, healthpsychology)ACSM Personal Trainer certification (see http://www.acsm.org/AM/Template.cfm?Section ACSM Certified Personal Trainer) orhigher (Health Fitness Specialist, Certified Clinical Exercise Specialist)Top tier personal trainer certification. See list below.Registered Dietitian (RD)BOC certification (athletic trainer)NCHEC Certified Health Educator Specialist [CHES]Registered Nurse (RN)Registered Pharmacist (RPh)Physician AssistantNurse PractitionerPhysical TherapistOccupational Therapist Registered (OTR)Physician (MD, DO)Doctor of Chiropractic (DC)Licensed/Registered Recreational Therapist or Certified Therapeutic Recreation SpecialistLicensed mental health professional including clinical psychologist, clinical social worker, marriage and familytherapist, professional counselor, psychiatric nurse practitionerYoga instructor: 200-hour certified, registered Yoga Alliance instructorAcceptable degree specialties Masters in Applied Positive PsychologyAthletic TrainingCommunity HealthExercise PhysiologyExercise ScienceHealth Care AdministrationHealth PromotionHealth PsychologyHealth ScienceHuman PerformanceKinesiology/KinesitherapyCoachCertApp 2011Page 5 of 7Updated: 05/01/2011

Coach Certification ApplicationNote: For renewals, please see "Coach Recertification Application". NursingNutritionOccupational TherapyPhysical EducationPhysical TherapyPhysician AssistantPhysiologyPublic HealthRecreation Management/ScienceSports ManagementTherapeutic Recreation/Recreational TherapyAcceptable Fitness Credentials AAAI/ISMA personal trainer certificationACE personal trainer certificationACSM personal trainer / fitness specialist certificationAFAA personal trainer/fitness counselor certificationAFLCA personal fitness trainer certificationBCRPA registered personal trainerCPTN certified personal trainerESA personal training/strength training certificationNAFC National Association for Fitness CertificationNASM personal trainer certificationNCCPT Certified Personal TrainerNCSF Personal Trainer CertificationNETA National Exercise Trainers AssociationNational Federation of Professional Trainers (NFPT)NSCA personal trainer certification or strength and conditioning specialistNSPA personal trainer certificationThe Cooper Institute physical fitness specialist certificationWITS personal fitness trainer certificationYMCA of the USA personal training instructor certificationHealth Coach Certification Prerequisite: Please submit a copy of evidence of one of the following prerequisites(including state licenses where appropriate). Prerequisite MUST be current:1.Bachelor’s degree, or higher in a health sciences-related field with direct medical knowledge and 2-yearspractical working experience2.ACSM Exercise Specialist or Registered Clinical Exercise Physiologist3.Certified Case Manager (CCM)4.Certified Diabetes Educator (CDE)5.Certified Physician AssistantCoachCertApp 2011Page 6 of 7Updated: 05/01/2011