Student Registration Form

Basic Information
Full Name*

First NameLast Name
Email *

Confirmation Email**Non-School Email Address Required**
Phone Number*
School You Are Enrolled At Currently *
Cleveland University – Kansas City College of Chiropractic
Anticipated Graduation Date*

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Date

Student Verification
Student ID *

Please upload a copy of your student ID for verification.
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Full-Time Student Schedule *

Please upload a copy of your full-time student schedule for verification.
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Clinical Neuroscience Program (Diplomate) / Functional Neurology Excellence Program
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.

EmailPhone CallText Message
Functional Neurology Excellence Bundle Options

Clinical Neuroscience & Functional Neurology Essentials - $9,980

Terms / Conditions
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.*

I Agree
Cancellation / Refund Information - All Carrick Institute courses are non-refundable and non-transferable.*

I agree to the terms and conditions - Carrick Institute courses are non-refundable and non-transferable. https://carrickinstitute.com/terms-conditions/
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.*

I agree
Do you have any notes you'd like to add to this registration form before we contact you?
Signature*

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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.
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