Level Two Registration- Bridge

Level Two requires successful completion of Level One: Educational Therapist Certification. Please confirm that you have completed Level One.

Please stop and do not continue with this registration. Level One must be completed before joining Level Two. Contact our team for assistance or register for Level One first.

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you affiliated with a school, church, or organization?

If yes, please list the name of the school, church, or organization.

Your Role or Title

Do you hold any licenses or certifications?

Do you currently have at least one year of active practice as a Bridge Educational Therapist?

How would you like to complete the Level Two live training?

If selecting in-person training, how many participants do you anticipate?

Do you have a target date to begin Level Two training?

Date

Do you have a desired timeframe to complete the training?

Certification Requirements and Cost Acknowledgment: I understand that Level Two includes live training (in-person or online), requires additional assessment materials purchased separately, and includes the responsibilities of providing educational screenings. I acknowledge the total cost of $1,500, with a $200 annual renewal fee to maintain certification.

If you select the payment plan, please call Lifeline at (205) 940-4707 to set up your online payments. Please select your payment option:

My Products

Bridge Level Two Registration Payment

PAY IN FULL

$1,500.00

Total

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Is there anything else you would like our team to know before beginning Level Two?

Level Two Registration

My Products*

My Products