First Name *

Last Name *

Are you a student or professional? *

I'm a student

I'm a healthcare professional

I'm a full-time faculty member

Phone *

Email *

By providing my phone number and email address, I agree to receive text messages and emails regarding the course.

Address *

City *

State *

Zip code *

Which Date and Location Will you Be Attending? *

What is the name of your school?

Professional Credentials?

State of Licensure

License Number

Expected Graduation Date

Choose how you'd like to pay for your ticket:

Pay-in-full and save 10% on your tuition or choose to pay in three equal installments over 6 weeks (1 payment every 3 weeks).

Payment Option

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