Basic Class Registration

Basic Class Registration
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Choose class date:
Are you a NeurOptimal system owner?
Please enter your name exactly as you would like it to be printed on your course completion certificate.
Comments/Questions:

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Full Payment - NeurOptimal Basic Certification Course

Pay in full to secure your spot today! Payment for courses is nonrefundable.

$660.00

Installment Plan - NeurOptimal Basic Certification Course

Pay a deposit of 50% of the class cost to hold your spot in the class. The remaining 50% of the class cost is due 30 days prior to the class start date; you will receive an invoice via email for the balance. This deposit is nonrefundable.

$330.00

Total

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

Basic Class Registration

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