Certificate Request Forms

If you plan to attend Graduation 2022, do not submit a request for a diploma/certificate.
Please fill out the graduation form and you will receive your diploma/certificate at the event.

Certificate Request Forms

Certificate Request Form for all Courses

First Name*
Last Name*
Please check off which certificate you are requesting*
- Clinical Neuroscience Program
- Concussion/mTBI
- ReceptorBased Essentials
- Pain Reset
- Human Performance
Please know that each certificate selected will be $35 each and your card on file will be billed. If you do not have a card on file, we will contact you for payment.
Name on Certificate*
First Last
Please fill out your name as you'd like it to be listed on your certificate.
Please choose an option below*
- Email
- Mail to physical address - $35 fee per certificate
Email

If you choose to email your certificate, you will receive it in two formats. Print ready and digital-ready.
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If you choose to have it mailed, a $35 fee will be invoiced to your email or charged to a card on file per certificate. Please allow 6-8 weeks to process and ship.
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Certificate Request Forms

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