New Class Registration

Class: Pro-ACT Training - Live stream (Pacific Time)

Class Registrant Information

The "Registrant" information below *MUST* be completed for the student - providing information specific to the person attending the training. The Email address must be unique for the Registrant. (ALL fields are required)

Registrant Email: *
Confirm Registrant Email: *
First Name: *
Last Name: *
Position: *
Agency Name: *
Secondary Email:
Home Address: *
City: *
State: *	--Select a State--Alberta, CanadaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingIncheon, South Korea
Zip: *
Day Phone: *
Cell Phone: *
Documentation Shipping Info
ShipTo First Name: *
ShipTo Last Name: *
ShipTo Street Address: *
ShipTo Apt/Suite:
ShipTo City: *
ShipTo State: *	--Select a State--Alberta, CanadaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingIncheon, South Korea
ShipTo Zip: *
This Address is a: *	- Residence  - Business Location
* - required field

Profile Admin Information (optional)

The Profile Admin is someone other than the Registrant with the ability to access the Registrant's profile as a way of providing support. This person will receive copies of all email correspondence to the Registrant / In-Service Instructor.

Profile Admin Email:
Confirm Profile Admin Email:
First Name:
Last Name:

Payment

While payment may be made by check, your class registration is not reserved and you will not have access to additional class information until payment in-full is received. Payment by credit card may be made on the following page and confirms your registration immediately.

Refunds and Dismissal Policy Review and Acceptance

The Pro-ACT, Inc. Refunds and Dismissal Policy may be reviewed by clicking HERE.

By checking this box , I certify that I have read and understand the Pro-ACT, Inc. Refunds and Dismissal Policy.

Submit Registration

Press the buttom below to submit the Registration data. You will be directed to the Payment page, where you will complete the payment transaction. You will receive an Email to confirm that we've received your information, along with further instructions.