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.
Now is the time to make final arrangements to attend. Take a few minutes to make your reservations.
You can now register electronically!
Enrollment forms & deposits are due: April 7, 2008.

Name:______________________________________ Date:___________

Address:________________________________________________________
_______________________________________________________________
_______________________________________________________________ Country:____________

Phone:____________________ fax:____________________ e-mail: ______________________

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) Who will you share a bedroom with _____________

Grand Total $____________ Deposit amount enclosed or authorized $__________

Balance due June 7, 2008 $________

Payment methods: US Check ____ (Must be in US Dollars and drawn on a US bank) (no bank transfers)

Visa /Mastercard (no American express) You can now register electronically!
Card Number _______________________________ Expiration date _______

Credit card authorization (signature)______________________________________________

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. List the level, Trainers, organization and date:
___________________________________________________________________________________________________

__________________________________________________________________________________________
Please make checks payable to NLP University and send your completed packet to reserve your place: P.O. Box 1112, Ben Lomond, California 95005 or if using a credit card: fax to (831) 336-5854 or register electronically.

NLP University Admissions Form

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 partcipants, 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 priviledged to offer these NLP programs at the UCSC campus, where NLP was founded. NLPU tries to maintain a conducive learning 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 Universtity.
OR print these forms and mail/FAX to Teresa Epstein at NLP Universtity.

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

The FAX number is:
831 336-5854

This page, and all contents, are Copyright © 2008 by Robert Dilts., Santa Cruz, CA.