Clone of Registration Form

1

Date

2

Name

First Name

Last Name

3

Email

example@example.com

4

Phone Number

Please enter a valid phone number.

5

If you are outside the US, please provide phone number with country code:

6

Program for which you are registering:

CELACare Mast Cell Health Certificate

CELACare Mast Cell Health Support: Direct Care Certificate

CELACare Mast Cell Health Support: Medical Professional Certificate

CELACare Mast Cell Health Support: Therapist Certificate

7

Terms and Conditions* This field is required.

8

Select your Payment Plan Option:

Payment Plan A - $21.00 per month for maximum of 6 months

Payment Plan B - $42.00 per month for maximum of 3 months

Payment Plan C - $63.00 per month for maximum of 2 months

Individualized Payment Option

9

Terms and Conditions* This field is required.

10

Checking below box acknowledges:

I have read, understand, and agree to the CELACare Payment Plan Terms & Conditions: (1) Payment is due according to Payment Plan I have selected on this form; (2) Payment will be made using through the CELACare Eco-Health, Inc. website using PayPal; (3) I have six months from date of registration to complete the certificate program; (4) I have a maximum of six months from date of registration to complete the payments or according to individualized payment plan; (5) Full payment must be completed successfully in order to receive my certificate.