Course Registration Form

( **  Required Information)

** Course:

** First Name:  

** Last Name:  

Employer:

Dept.:

Address of:
(if you prefer to have correspondence sent to your home, please check Home and give appropriate address)
      

** Address: 

** City:

** State:

** Zip Code:

** Country:

** E-mail:

** Phone:
, Extension

FAX:
, Extension

Comments:


Enter Verification Code listed above:

Payment and Refund Policy:  Larry Head Institute reserves the right to terminate student registrations that are not paid in full two weeks prior to the course. Payment can be made by check, money order, or credit card.

Refunds requested more than two weeks prior to the course will be refunded in full. Requests for refunds received seven to fourteen days prior to the course are subject to a $100.00 administrative fee. Refunds are not issued for registrations occurring within seven days of the course.

Please visit the FAQs section if you have any further questions or contact us for additional information.