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:
March 6, 2010 for Master Practitioner and Master Trainer Programs
April 6, 2010 for Practitioner and Trainer Consultancy Programs.
Classes may be open, with places available, until the class begins, please
check with Teresa: TeresaNLP@aol.com
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) With whom will you share a bedroom? _____________
Grand Total $____________ Deposit amount
enclosed or authorized $__________
Balance due May 6, 2010 for Master Practitioner or Master Trainer
Programs: $________
June 6, 2010 for Practitioner or Trainer
Consultancy Programs: $________
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 ____________
3 digit number of the back of card __ __ __
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 (503) 738-9546 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 mail/FAX to Teresa
Epstein at NLP University.
The mailing address is:
Teresa Epstein
P. O. Box 1112
Ben Lomond, CA 95005
The FAX number is:
(503) 738-9546
This page, and
all contents, are Copyright © 2009 by Robert Dilts., Santa Cruz, CA.