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COURSE REGISTRATION FORM
Indicate the date and the location of
the course you wish to attend:
Course Date and
Location:_______________________________________________________________
Home Address
Name:________________________________________________________________________________
Street:________________________________________________________________________________
City, State,
Zip:________________________________________________________________________
Work Address
Business Name,
Department:_____________________________________________________________
Street:________________________________________________________________________________
City, State,
Zip:________________________________________________________________________
Phone: (daytime)____________________
(evening)_________________ E-mail:__________________
Please indicate your
profession and enclose a copy of your license or
diploma/certificate with your registration
Please Circle P.T
P.T.A O.T O.T.A M.D R.N M.T (*)
Other:_____________________
(*Massage
Therapists must show proof of completion of a minimum of 500
hour training program or be certified through the National
Certification Board for Therapeutic Massage and Bodywork (NCBTMB).
Massage Therapists from outside the U.S. must show proof of
equivalent International program)
Payment: The full tuition
for the certification course is $2,500.00. A deposit of
$500.00(*) is required at the time of registration and will hold
your spot until the full payment of the tuition is received two
(2) weeks prior to the first day of class. You may also choose
to pay the full tuition of $2,500.00 at the time of
registration.
(*$100.00 is
non-refundable; $250.00 becomes non-refundable once you receive
the course book containing the home study materials)
To register please complete this form
and return it with your professional license,
diploma/certificate and the applicable deposit payable in check,
money order or credit card to:
Academy of
Lymphatic Studies
11632 High Street, Sebastian, FL 32958
My check or money order in U.S. currency payable
to the Academy of Lymphatic Studies is enclosed
Please charge my VISA or MASTER CARD (circle one)
in the amount of: $___________________
Credit Card
Number:________________________________________ Exp.Date:_______________
Date:___________ Your
Signature:_______________________________________
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