Please select which class level and dates you plan to attend. Please select which class level and dates you plan to attend. Online Level 1 - To Be Determined (post COVID-19)

First Name

Last Name

Email Address

Address

City

State

Zip Code

Cell Phone Number

Home Phone Number

Precise Name on Certificate -Middle Name? Initial? (No designations please)

I understand that my payment is non-refundable but may be applied to a future class within 12 months. I understand that my payment is non-refundable but may be applied to a future class within 12 months. Yes

I am taking an online Kinesiology Class and I am... I am taking an online Kinesiology Class and I am... 18 years-old or older. 16 or 17 years-old and will be accompanied by a paying parent or guardian.

Please select one. Please select one. I understand I must be present during all of the class times in order to receive CEs and I will bring my professional license number to class for the appropriate paperwork. I am not needing CEs but plan to attend all class times.

I acknowledge that I may receive periodic emails from Teresa Jantz/Touchpoint Therapy before and after our class. I acknowledge that I may receive periodic emails from Teresa Jantz/Touchpoint Therapy before and after our class. Yes

I opt-in to receive Touchpoint Therapy newsletters. I opt-in to receive Touchpoint Therapy newsletters. Yes, please. No, not at this time.

How did you hear about this class? Please choose all that apply. How did you hear about this class? Please choose all that apply. Internet search Internet search for Teresa Jantz TouchpointTherapy website Facebook Instagram Word of Mouth Advertisement Email from Teresa Jantz/Touchpoint Therapy Teresa Jantz Other (Please explain in message box directly below)

Any extra Message (Optional)