Certificate of Completion & Therapist Directory Registration

First Name^*

Last Name^*

Professional Title^*

Home Address^*

City^*

State^*

Zipcode^*

Phone^*

Business Name

Department

Business Address

City

State

Zipcode

Course Location & Date^*

Would you like to be listed on our therapist referral list?^*

Yes No

Consent to Release the Above Information

I understand and agree to the terms and conditions of this agreement to have the above information made available to patients seeking treatment, allied healthcare professionals for referral and lymphedema suppliers seeking to market products and services.
I also agree to be listed as indicated above on the Norton School "Therapist Resource Directory" found on the Norton School homepage. I understand that I may cancel this agreement anytime by sending a cancellation notice to: Norton School of Lymphatic Therapy, 1095 Cranbury South River Road, Suite 24, Jamesburg, NJ 08831. I further agree that checking the "I Agree to the Terms and Conditions" box, entering my full name in the "Full Name" box, and entering a valid e-mail address in the "E-Mail Address" box collectively constitute an electronic signature* thereby rendering this Agreement valid and legally binding.

I Agree to the Terms & Conditions^*

Full Name^*

Email^*

* Required Field