NLP University Admissions Form
Enroll now and start planning your summer of learning and exploration.

We guarantee that if for any reason you need to change your plans, we will fully refund your money minus a $250 cancellation fee.
Now is the time to make final arrangements to attend. Take a few minutes to make your reservations.
You can also register electronically!

Enrollment applications and deposits are due: March 15, 2012 for Practitioner Certification and Trainer and Consultancy Certification
and April 15, 2012 for Master Practitioner Certification and Master Trainer, Facilitator, Entrepreneur Certification.

Please contact Teresa to enroll: Email TeresaNLP@aol.com or call (831) 336-3457

Registration on campus takes place at the University of California (UCSC):
July 9, 12-2 PM and August 5, 12-2 PM
1156 High Street, Santa Cruz, CA 95064

Name:________________________________________ Date:_____________

Address:________________________________________________________

________________________________________________________________

_______________________________________________________________ Country:____________

Phone:______________________ Fax:______________________ Email: _______________________

Please list any relevant professional qualifications that you have:

__________________________________________________________________________________

Please list your educational degrees or diplomas. Include the institution and date:

__________________________________________________________________________________

Please list any NLP certification you have received. Include the level, trainer(s), organization and date:

__________________________________________________________________________________

__________________________________________________________________________________

Which NLP University Course(s) are you applying for?

#________________________ Dates _________________ Deposit $____________Total due $_______

#________________________ Dates _________________ Deposit $____________Total due $_______

Residential package ____ Yes ____ No ____ Male ____ Female ____ Smoking?

____ Single ____ Double ($15.00 less each night) With whom will you share a bedroom? _____________

Grand Total $____________ Deposit amount enclosed or authorized $__________

Methods of Payment:

____ Bank Check NLPU prefers that you send a check in US Dollars. At your bank you can ask for a check to be made out to NLP University and then send it to:
NLP University, P.O. Box 1112, Ben Lomond, California 95005, USA

or
____ Bank Transfer If you would like to make a bank transfer, please transfer to the NLP University Account.
For details contact: TeresaNLP@aol.com

or
____ Visa /Mastercard (sorry, no American express)

Card Number ______________________________________ Expiration date ____________

3 digit number of the back of card __ __ __

Credit card authorization (signature)______________________________________________

NOTE: For added security, send the credit card numbers in 2-3 separate emails.

Deposit Authorized Now: $ ____________

Payments for Balance Authorized: ______________________________________

or

Some Cash US Dollars can be paid at Registration.

or

A Payment Plan, guaranteed with a Visa or Mastercard, can be arranged.

If you decide to cancel for any reason, all the money you have paid is 100% refundable minus a $250 cancellation fee.

Please make checks payable to NLP University and send your completed packet to reserve your place.

Email this form to: TeresaNLP@aol.com

Or Mail Printed Copy to: P.O. Box 1112, Ben Lomond, California 95005, USA

Or Register Electronically

Confidential Participant Information Sheet / Please Read Carefully, Answer, and Sign:

Are you or have you recently been using any kind of medication? ___Yes ___No If yes, what kind(s)?

__________________________________________________________________________________

__________________________________________________________________________________

Are you or have you recently been under the care of a doctor, psychiatrist or psychologist? _______

History of mental illness in family? ____ Please explain:

__________________________________________________________________________________

__________________________________________________________________________________

Do you have physical problems or disabilities for which you will need assistance? ____ Please explain:

__________________________________________________________________________________

If you are currently under the care of a doctor, psychiatrist or psychologist, please provide us with the appropriate contact information below, including telephone numbers.

1._________________________________________________________________________________

2. ________________________________________________________________________________

The University of California, where NLPU is held, does not allow inappropriate use of drugs or alcohol on campus.

Please indicate if you have had a dependency problem. ____

Emergency Contact Information: All participants, please provide the names and telephone numbers at work and home for two people that we can be in contact with in case of an emergency.

1._________________________________________________________________________________

__________________________________________________________________________________

2._________________________________________________________________________________

__________________________________________________________________________________

The undersigned clearly understands: The education being provided is solely for avocational / recreational purposes and not to provide training for employment. Such education is being pursued for personal entertainment, recreation, individual edification or as a hobby.

Participants at NLP University are expected to behave respectfully and ethically toward fellow participants, NLP University and University of California staff. Participants who disrupt the educational flow of NLPU with inappropriate behavior will not be assessed for certification and may be asked to leave the campus.

NLP University's right to deny entry into a program is reserved.

The University campus is a special learning environment. We feel privileged to offer these NLP programs at the UCSC campus, where NLP was founded. NLPU tries to maintain a learning conducive environment and would appreciate your cooperation in following the guidelines. Please feel free to check with NLP University if you have questions.
Thank you for your consideration.

Signature:_____________________________________ Date: ______________

Please Copy and Email these forms to Teresa Epstein at NLP University.
OR Print these forms and email or mail to Teresa Epstein at NLP University.

The mailing address is:
Teresa Epstein
NLP University
P. O. Box 1112
Ben Lomond, CA 95005
USA

NLP University Admissions Form Enroll now and start planning your summer of learning and exploration.

NLP University Admissions Form
Enroll now and start planning your summer of learning and exploration.