Student Registration Form

Student Registration Form
- Full Name
  
  First NameLast Name
- Email
  
  Confirmation Email**Non-School Email Address Required**
- Phone Number
  Format: (000) 000-0000.
- School You Are Enrolled At Currently
  Cleveland University – Kansas City College of Chiropractic
- Anticipated Graduation Date
  
  MonthDayYear
  Date
- Student Badge
  
  Please upload a copy of your student badge for verification.
  Cancelof
- Full-Time Student Schedule
  
  Please upload a copy of your full-time student schedule for verification.
  Cancelof
- 3 Day - Adjusting Techniques in Functional Neurology - Student Tuition $149
- 2 Day - Evidence-Based Muscle Testing for Peripheral and Central Nervous System Applications - With Dr. Norman Hoffman - Student Tuition $149
- Concussion Bootcamp - Student Tuition $99
- Advance Chiropractic Techniques with Prof. Carrick - Student Tuition - $149
- Self-Paced Learning (On-Demand) Synapse Sessions - Student Tuition $99
- Self-Paced Learning (On-Demand) We S.H.I.N.E. - Student Tuition $99
- 2025-2026 Student Webinars - Free
- Self-Paced Learning (On-Demand) - Free
- If you're interested in enrolling in the Diplomate Program or Clinical Neuroscience Program and would like to speak with a faculty advisor, please indicate your preferred contact method so we can help arrange the perfect education option for you.
- Functional Neurology Excellence Bundle Options
- I understand that a team member will be contacting me by email on the next steps on processing my registration and this form does not guarantee my registration.
- Cancellation / Refund Information - All Carrick Institute courses are non-refundable and non-transferable.
- I/We understand that this is a legally binding contract and that my signature below certifies that I have read, understood, agreed, and that the cancellation and refund policies have been clearly explained to me.
- Do you have any notes you'd like to add to this registration form before we contact you?
- Signature
  
  Type Your Name To Confirm Your Digital Signature - DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
- Should be Empty: