CE Course Registration Form (MHFA, QPR, VC)

MHFA, QPR, or VitalCog Course Registration

Haugen Performance Consulting & Assessment & Therapy Associates of Grand Forks
Please fill out this brief registration form to ensure all information required by licensing boards is on your certificate of credit.

Once you have filled out this form, you will be redirected to the payment page for the course you select.

Please ensure you do not have pop-ups blocked for this page, as that may interfere with you being redirected to the payment page.
- You will not be entered into the course until you have paid for it, so if you are not redirected to the payment page, please contact us so we can assist you!
- These courses are NOT recorded, so you must attend the scheduled live event to obtain CE credits.
If you have any questions, please contact HPC via email at hello@haugenperformance.com.
Name*

First NameLast Name
Email (this MUST match the email you will use for our course portal)*
example@example.com
Profession*
List each state and your corresponding license number (write "n/a" if you do not have a license number)*
Example: ND #1432; SD #20548
Company or organization that you are affiliated with*
Name of certification course you are registering for (they are listed in alphabetical order):*
After you submit this form, you'll be automatically redirected to the payment page for your selected course.
Approximately how many athletes do you interact with yearly (please provide a numerical estimate)?*
This helps us estimate the impact of the course.
Approximately how many non-athletes do you interact with yearly (please provide a numerical estimate)?*
This helps us estimate the impact of the course.
Is there any information you feel would be beneficial for your instructor to know that would impact your experience of this course (type n/a if not applicable)?*
Name of your emergency contact*

First NameLast Name
Phone number of your emergency contact*
Please enter a valid phone number.
Should be Empty:

MHFA, QPR, or VitalCog Course Registration