Healthy Children's Courses and Conferences

Registration Form

First Name:^*
Middle Initial:
Last Name:^*
Organization:

Type of Address^*
PO Box / Mail Stop:
Primary Address:^*
City:^*
State:^*
Zip:^*
Country:
Phone 1:^*	ext.
Phone 2:	ext.
Email:^*
Fax:

Continuing Education Credit

RN License #:
RN License State:
RD #:
IBCLC #:
IBCLC Exam Year:
CNM #:
Titles:

Registration Information

Location:^*

Class Tuition

Regular Tuition (per person)
$625 (US)	Regular Tuition
$575 (US)	Early Bird ^**
Group / Agency Rate Tuition^***
$575 (US)	Regular Tuition
$525 (US)	Early Bird ^**
Agency:

** Early Bird: An early registration discount of $50 is available if your
check or credit card information is received 4 weeks (28 days) prior
to the beginning of the training.
*** A group discount is available when 4 or more people from the same agency register and identify themselves as part of that agency. The group must be identified at the time of registration. Group discounts will not be given retroactively.

Application and Exam Fees

The Certified Lactation Counselor ® Exam is administered by the
Academy of Lactation Policy and Practice (ALPP)

$120 (US)	CLC Exam Fee (includes $20 Application Fee)
$0 (US)	Not taking the CLC Exam

Textbook

The Pocket Guide for Lactation Management will be used during class and for homework. Participants may share books. This textbook can be purchased as you register, through our website, or from Amazon.com.

$55 (US)	Pocket Guide for Lactation Management
$0 (US)	No Pocket Guide

Additional 175 CEU Hours

Optional Additional 175 CEU hours (must be combined with full course and exam)

$350 (US)	Additional 175 CEU Hours
$0 (US)	No Additional CEU Hours

Notes

Payment Information

We are unable to hold a place for you without payment or a purchase order number.
If you are paying by credit card, please provide the address and information
associated with the credit card.

My Billing information is the same as above

First Name:^*
Last Name:^*
Organization:
Address:^*
City:^*
State:^*
Zip:^*
Billing Phone:^*	ext.
Email:^*
Payment Type^*
Credit Card #^*
Exp (MM/YY)^*
Verification #^*
PO#^*

$25 per person surcharge for POs / bill your agency

***The VCode is the 3 digit number on the back of your MC/VISA/Discover, or 4 digit number on the front of your AmEx.

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Lactation Counselor Training Course