Registration Form

Norton School of Lymphatic Therapy Basic MLD Certification Course Registration Form
750 State Route 34 • Suite 7 • Matawan, NJ 07747
(866) 445-9674 Toll-Free • (866) 854-7800 Fax

DESIRED COURSE DATE AND LOCATION
Course Date:	Course Location:

CONTACT INFORMATION

Name:		Business Name:
Home Address:		Business Department:
Home City, State & ZIP:		Business Address:
Home Phone:		Business City, State & ZIP:
Mobile Phone:		Business Phone:
FAX:		E-Mail:

PROFESSIONAL TITLE

REGISTRATION AND PAYMENT

The total tuition for the course is $850. The Norton School can accept payment by check or credit card. A deposit of $300 is required at the time of registration and will hold your spot until the total amount is received no later than two (2) weeks prior to the first day of class.

Please note that by submitting your registration you are accepting the Student Agreement as outlined on the Student Agreement page. Please indicate with your signature below that you have read the Student Agreement and agree to the terms as specified.

Signature: _______________________________ Date: ____________

To register, please mail or fax this registration form along with a $300 deposit paid by check or credit card and a copy of your professional license/diploma.

Payment Type:

Credit Card:

Mastercard

VISA

American Express

Discover

Card Holder's Name:

Account Number:

Exp. Date (MM/YY):

Check:

Made payable to "Norton School of Lymphatic Therapy"

Financial Aid:

(We will contact you to begin your application process.)

NOTE: If you are paying by credit card you may either include the information in the area above or call us to provide the information by phone.

TRAVEL AND ACCOMMODATIONS

Would you like to receive hotel information?	yes	no
Would you like to receive directions?	yes	no
Would you like to have your name and phone number given to other students for room sharing?	yes	no