Participant Information

Contact Info

First Name*

Last Name*

Email*

Phone *

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Address Line 1*

Address Line 2

City*

State/Province*

Postal Code*

Country *

Additional Information for Your Order

Home Phone:*

Nominated By:*

Relationship:*

Company Name:*

Type of Company:*

Position / Title:*

Business Street Address (Including City, State, Zip Code and Country):

Emergency Contact Name:*

Emergency Contact Relationship:*

Emergency Contact Phone:*

How should your name appear on the certificate?*

My primary reason for participating in this class is:

How did you find out about us?*

Class Dates: (Choose One)*

Read and Sign Waiver

Terms of Acceptance: Either party may not cancel this agreement. Full attendance in each session is required. ONLY in the case of an unexpected emergency, may I attend the next class of my choice. Pulling out of a class 7 days prior (or less) to class date will result in a forfeiture of hotel & meal expenses. Refunds are not allowed. Participant acknowledges that participant has read this agreement and agrees to the terms and conditions herein.

I, the participant for this class, warrant the truthfulness of the information provided in this application and I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the Terms of Acceptance. There are no refunds.

Your birthdate

IP: 18.97.14.89
Jan. 20, 2025

By clicking I agree to the terms.