Enrollment Form

Please fill out the form completely and accurately.

Full Name (*)

Please let us know your name.

Email (*)

Please let us know your email address.

please re-enter youe email address (*)

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Mailing Address (*)

We will use this address to send materials, please ensure it is accurate.

City (*)

Please tell us what city you live in.

State (*)

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Zip (*)

Please fill in your zip or postal code.

Home Phone (*)

Cell Phone

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Gender
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Date of Birth (*)

Please fill in your Date of Birth.

Background & Education Information

Race (*)

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We collect demographic information for informational & grant seeking purposes only.

This will not affect enrollment.

Education Level (*)

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Employment Status (*)

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Other Credentials

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Do you have any other credentials, medical affiliations or relevant qualifications?

If so, please describe:

Anticipated Start Date (*)

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Program Preferences

What program do you plan to enroll in? (*)

Please Make A Program Choice (prices listed do not include workshop fees which are required for certification)

Tuition Preference
(*)
I plan to pay all my tuition and workshop fees, in full, immediately.

I plan to pay for my tuition in full now but I will wait to pay for my workshop.

I am paying for an upcoming workshop now but will not join the program and pay tuition until after I have attended.

I plan to pay part of my tuition and fees and an outside source (i.e employer, scholarship, friend) will be responsible for the remaining balance.

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How did you find out about BWI?
(*)

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What makes BWI the best fit for you personally? (*)

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Workshop Preferences

Is there an upcoming workshop that you are planning to attend? (*)

Invalid Input Please let us know if there is a workshop you plan on attending already.

Are you willing to travel in order to complete the workshop reqirement?
(*)
I am not willing to travel.

I am willing to travel as long as it is driving distance.

I am willing to travel, even if it means flying to another city.

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Are you interested in hosting a workshop?
(*)
I have read the guidelines and am very interested in hosting a workshop.

I have not read about hosting a workshop but I am interested in finding out more.

I am not interested in hosting a workshop.

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How would you prefer to be contacted? (*)

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