I ____________________ (print your name)

Declare that I

WANT_______________________

So that I can Be, Do and Have the following

OUTCOMES___________________

I acknowledge that there will be

OBTACLES such as_______________

As I live my

PASSION by___________________

But I will take

ACTION by ___________________

And celebrate my

SUCCESS by___________________

I solemnly promise to

SUPPORT myself through this process by ______________________ ____

SIGNED:_____________________

DATE:__________

WITNESSED BY:________________

DATE: ___________