Level One Registration- Bridge

Do you have minimum 2 years of college education or an associates degree?*

YesNo

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?*

YesNo

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?*

Online through the Lifeline EducationLive in-person training (requires a group of 3-4+ participants)Undecided

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

Just meA group of 3-4 peopleA group of 5+ peopleUndecided

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

Date

Do you have a desired timeframe to complete the training?*

Within 1-2 monthsWithin 3-4 monthsWithin 6 monthsFlexible/ Undecided

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.*

Yes, I understand and agree.I have questions before committing.

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

Pay in full ($1,500)Four-month payment plan

My Products*

Bridge Level One Registration Payment

PAY IN FULL

$1,500.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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

Level One Registration- Bridge Educational Therapy