NLP University Enrollment Form
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NLP University Enrollment Form
Enroll now and start planning your summer of learning and exploration.
Now is the time to make final arrangements to attend. Take a few minutes to make your
reservations.
We guarantee that if for any reason you need to change your plans, we will fully refund your
money minus a $250 cancellation fee. Enrollment applications and deposits are due: NOW.
Name:_____________________________________________ Date:___________
Address:____________________________________________________________
City:________________________________ Province/State:_________________
Postal Code:____________________ Country:____________________________
Email:_________________________ Website:_____________________________
Telephone:_________________________
Please list any relevant professional qualifications that you have:
_____________________________________________________________________
Please list any NLP certification you have received. Include the level, trainer(s),
organization and date:
______________________________________________________________________
______________________________________________________________________
Please describe the nature of the project you would like to pursue while you are at NLP
University this summer:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Copyright © 2015 NLP University
NLP University Enrollment Form
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NLPU 450 INDEPENDENT STUDY ENROLLMENT OPTIONS
______ Master Practitioner Residential Program: $4,025 US dollars. (Includes tuition, private
accommodations, meals. Smoking is not permitted on the U.C. Santa Cruz campus.)
____ Male
____ Female
____ Single
____ Double (minus $15 per night)
If Double with whom will you share a bedroom? __________________________
______ Master Practitioner Tuition Only: $2,400 US dollars.
______ Trainer and Consultancy Residential Program: $4,375 US dollars. (Includes tuition,
private accommodations, meals. Smoking is not permitted on the U.C. Santa Cruz campus.)
____ Male
____ Female
____ Single
____ Double (minus $15 per night)
If Double with whom will you share a bedroom? __________________________
______ Trainer and Consultancy Residential Program Tuition Only: $2,500 US dollars.
______ Deposit: $2,400 US dollars for Master $2,500 US dollars for Trainer. (Holds your place
in the course. Applied toward total fees.)
Grand Total $____________ Deposit amount enclosed or authorized $__________
METHODS OF PAYMENT
____ Bank Check NLPU prefers that you send a check in US dollars. At your bank you can ask
for a check to be made out to NLP University and then send it to:
NLP University, P.O. Box 1112, Ben Lomond, California 95005. USA
or
____ Bank Transfer If you would like to make a bank transfer, please transfer to the NLP
University Account:
Bank of America, 300 S Holladay Dr., Seaside, Oregon 97138 USA
Telephone: 503 738-8311
This is all you need: Swift Code BofAUS3N
NLP University Checking Account: 485003913764 Wire transfer routing #: 026009593
or
Copyright © 2015 NLP University
NLP University Enrollment Form
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____ Visa ____ Mastercard (sorry, no American Express) Card Number _________________________________ Expiration Date ___________
3 digit code on back __ __ __ Credit Card Authorization (Signature) _________________________________________
NOTE: For added security, send the credit card numbers in 2-3 separate emails. Deposit Authorized Now $_______________ Payment(s) for Balance Authorized: _______________________________________
or
____ Some Cash US Dollars can be paid at Registration.
or
____ A Payment Plan, guaranteed with a Visa or Mastercard, can be arranged.
If you decide to cancel for any reason, all the money you have paid is 100% refundable, minus a
$250.00 cancellation fee. Please make checks payable to NLP University and send your completed packet to reserve
your place. Copyright © 2015 NLP University
NLP University Enrollment Form
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CONFIDENTIAL PARTICIPANT INFORMATION SHEET
Please read carefully, answer, and sign.
Are you or have you recently been using any kind of medication? ____Yes ____No
If yes, what kind(s)? ________________________________________________________
__________________________________________________________________________
Are you now or have you recently been under the care of a doctor, psychiatrist or
psychologist? ______________________________________________________________
Is there a history of mental illness in your family? _______ Please explain: __________________________________________________________________________
__________________________________________________________________________
Do you have physical problems or disabilities for which you will need assistance? ________
Please explain: ______________________________________________________________
__________________________________________________________________________
If you are currently under the care of a doctor, psychiatrist or psychologist, please provide us
with the appropriate contact information below, including telephone numbers:
1._________________________________________________________________________
2._________________________________________________________________________
The University of California, where NLPU is held, does not allow inappropriate use of drugs or
alcohol on campus.
Please indicate if you have had a dependency problem: ______________________________
Emergency Contact Information: All participants, please provide the names and telephone
numbers at work and home for two people that we can be in contact with in case of an
emergency.
1._________________________________________________________________________
__________________________________________________________________________
2._________________________________________________________________________
__________________________________________________________________________
Copyright © 2015 NLP University
NLP University Enrollment Form
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The undersigned clearly understands: the education being provided is solely for the
avocational / recreational purposes and is not intended to provide training for employment. Such
education is being pursued for personal entertainment, recreation, individual edification or as a
hobby.
Participants at NLP University are expected to behave respectfully and ethically toward fellow
participants, NLP University and University of California staff. Participants who disrupt the
educational flow of NLPU with inappropriate behavior will not be assessed for certification and
may be asked to leave the campus.
NLP University's right to deny entry into a program is reserved.
The University campus is a special learning environment. We feel privileged to offer these NLP
programs at the UCSC campus, where NLP was founded. NLPU tries to maintain an
environment conducive to learning and appreciates your cooperation with these guidelines.
Please feel free to check with NLP University if you have questions.
Thank you.for your consideration.
Signature: _______________________________________ Date: _______________
Please copy and email these forms to Teresa Epstein at NLP University.
OR Print these forms and mail them to Teresa Epstein at NLP University.
The mailing address is:
Teresa Epstein
NLP University
Post Office Box 1112
Ben Lomond, California 95005 USA
Copyright © 2015 NLP University