Video Lessons Access Application Form

First Name

Last Name

Phone *

Email *

Certification Details

Certification Level: *

Current Certification Status: *

Initial Certification Date: *

Note: If you certified less than two years ago, please enter your original certification date in both the Initial Certification Date and Last Recertification Date fields. If you have recertified within the last two years, please provide your most recent recertification date in the appropriate field. This will help us verify your active certification status efficiently. Thank you!

Last Recertification Date: *

Event attended for recertification: *

Senior Trainer Name: *

Location: *

I certify that the information provided above is accurate and up to date.