Level One Registration- Bridge

Level One Registration- Bridge Educational Therapy

After the completion of this form, you will receive a welcome email that will have more details about next steps moving forward. This will clarify more about the Bridge Educational Practitioner training/program and provide you the ability to ask questions.
Do you have minimum 2 years of college education or an associates degree?
If you would like to talk with a member of our team about possibly moving forward, please submit your contact information below.
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 have experience working with children? If yes, how many years and in what capacity?
How would you like to complete the core Level One Training?
If selecting live in-person training, how many participants do you anticipate?
Certification Requirements and Cost Acknowledgment: I understand that Level One includes the core online or live training, eight individual supervision sessions, and four collaborative group calls. 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:

Is there anything else you would like our team to know before beginning Level One?
Should be Empty:

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

Level One Registration- Bridge Educational Therapy

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