Attraction Into Action Day-Survey

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

E-Mail Address*

Time Zone

You may use my comments on your website or promotional materials*

	Yes
	No

If yes, please indicate for use of your name

	I would like to be anonymous-please do not use my name or initials
	First and last name
	First initial and last name only
	First initial and last initials only

The Attraction Into Action Day was valuable to me in the following ways:

This made a difference because:

Aha’s, awarenesses, epiphany’s:

Suggestions for improvement:

Feedback for Coach Estelle:

I am interested in attending additional Attraction Into Action Days

	Yes
	No

Please indicate which of the following times
are the best for you to attend

Add Me to Your Mailing List for upcoming teleclasses and events

	Yes
	No

Other Comments:

Please enter the word that you see below.