Certification Supplemental Program Application

With equipment like the Baby Arm Chair, the Guillotine and a host of other small devices, our short courses can arm you, your team and your program with the tools you need to address special populations like athletes, men, seniors and the post-rehab population.

Name * First Last
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone * - (###) - ### ####
Work or Cell Phone * - (###) - ### ####
Email *
Date of Certification * / MM / DD YYYY
Certifying Organization *
Current Employer *
Employed Since * / MM / DD YYYY
Number of Participants you are applying for: *
Have Participants completed their certification? * Yes No
If no, when is completion expected? *
Please provide potential dates of availability for your group
Date 1 * / MM / DD YYYY
Alternate Date * / MM / DD YYYY
Alternate Date 2 / MM / DD YYYY
Cancelation Agreement
Space is limited. We reserve the right to cancel any workshop 14 days prior to program date. * I have read and understand the cancellation policy and agree to its terms.

Certification Supplemental Program Application

Certification Supplemental Program Application

Please provide potential dates of availability for your group

Cancelation Agreement