Full Name:

Email Address:

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Preferred Method of Contact:
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Please Indicate your Professional Title:
Chiropractor (DC)Physical Therapist (PT)Osteopath (DO)Medical Doctor (MD)Neurologist (MD or DO)Other

If other , please specify:

Please Provide:
Licensure Type, License Number, Issuing State, Province, or Country

Is your license current?:
YesNo

Are you legally permitted to:
AdjustMobilizeManipulateNone of the above

Education Background: Graduation Year, Name of Educational Institution, Location (City, State, or Country):

Practice Name (If Applicable):

Website or Social Media Handle:

Years in Practice:
0 to 2 years3 to 5 years6 to 10 yearsmore than 10 years

What are you most interested in learning from this course? Check all that apply:
Structural Analysis and CorrectionNeurological IntegrationRehabilitation ProtocolsFrozen ShoulderTic Disorders, ADHD, and Neurological SyndromesGut-Brain Axis and Autonomic FunctionPractice Growth and DifferentiationResearch and DataTeaching NSG in the Future

International Inquiries (only if you practice outside the U.S.)

Country:
—Please choose an option—AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua & DepsArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia HerzegovinaBotswanaBrazilBruneiBulgariaBurkinaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepChadChileChinaColombiaComorosCongoCongo {Democratic Rep}Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIreland {Republic}IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar, {Burma}NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussian FederationRwandaSt Kitts & NevisSt LuciaSaint Vincent & the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Regulatory or Licensing Body:

Is Chiropractic or manual therapy legally recognized in your country?
YesNo

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You also acknowledge that this form does not guarantee enrollment,
and that you meet all licensing requirements in your area.

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