Phone: (318) 322-8323
Fax: (318) 340-9865
Navigation
Home
Seminars
Assessment / Treatment
Falls In The Elderly
Identifying Fall Risks
Outside the Box
Stress
On-Site Seminars
Online Registration
About Us
Contact Us
Links
Cart
Blog
You are here
Home
ยป Online Registration
Online Registration
Use the form below to register. If you would prefer to fill out the registration form offline, you can print the offline registration form and mail it in with your check, cashier check or money order.
Offline Registration Form
Name as it will appear on certificate
*
Professional Credentials
*
- Select -
PT
PTA
OT
OTA
RN
LPN
MSW
Administrator
Other
Professional Credentials Other
License #
*
License Renewal Date
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Address
*
Address Line 2
City
*
State
*
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Phone #
*
Work #
*
Cell #
*
Email
*
Employer
*
Seminar
*
Terrell, TX - 12/12/19 [$210.00]
Hammond, LA - 01/16/20 [$185.00]
Lafayette, LA - 01/17/20 [$185.00]
Waco, TX - 03/04/20 [$185.00]
Tyler, TX - 03/05/20 [$185.00]
Shreveport, LA - 03/06/20 [$185.00]
Alexandria, LA - 03/19/20 [$185.00]
Monroe, LA - 03/21/20 [$185.00]
Covington, LA - 03/30/20 [$185.00]
Hattiesburg, MS - 05/06/20 [$185.00]
Brookhaven, MS - 05/07/20 [$185.00]
Oklahoma City, OK - 05/14/20 [$185.00]
Lawton, OK - 05/15/20 [$185.00]
Florence, AL - 05/28/20 [$185.00]
Columbus,, MS - 06/04/20 [$185.00]
Jackson, TN - 06/06/20 [$185.00]
Lawrence, KS - 06/17/20 [$185.00]
Salina, KS - 06/18/20 [$185.00]
Wichita, KS - 06/19/20 [$185.00]
Kenner, LA - 07/08/20 [$185.00]
Baton Rouge, LA - 07/10/20 [$185.00]
Gadsden,, AL - 07/20/20 [$185.00]
Birmingham, AL - 08/12/20 [$185.00]
El Dorado,, AR - 08/20/20 [$185.00]
Jonesboro, AR - 08/31/20 [$185.00]
Panama City Beach, FL - 09/09/20 [$185.00]
Pensacola, FL - 09/10/20 [$185.00]
Sanford, FL - 09/16/20 [$185.00]
Ocala,, FL - 09/17/20 [$185.00]
Lake City, FL - 09/18/20 [$185.00]
Hot Springs, AR - 10/06/20 [$185.00]
Russellville, AR - 10/07/20 [$185.00]
Gulfport, MS - 10/14/20 [$185.00]
McKinney,, TX - 11/18/20 [$185.00]
Paris, TX - 11/19/20 [$185.00]
Longview,, TX - 11/20/20 [$185.00]
Crestview, FL - 12/09/20 [$185.00]
Destin, FL - 12/10/20 [$185.00]
Shreveport, LA - 12/14/19 [$210.00]
Houma, LA - 01/15/20 [$185.00]
Ruston, LA - 02/05/20 [$185.00]
Alexandria, LA - 02/06/20 [$185.00]
Lafayette, LA - 02/12/20 [$185.00]
Hammond, LA - 02/21/20 [$185.00]
Meridian, MS - 03/11/20 [$185.00]
Hattiesburg, MS - 03/12/20 [$185.00]
Shreveport, LA - 03/20/20 [$185.00]
Vicksburg, MS - 04/04/20 [$185.00]
Ft. Smith, AR - 04/29/20 [$185.00]
Conway, AR - 04/30/20 [$185.00]
Madison, AL - 05/29/20 [$185.00]
Tupelo,, MS - 06/05/20 [$185.00]
Dothan, AL - 07/16/20 [$185.00]
Gadsden, AL - 08/13/20 [$185.00]
Searcy, AR - 10/02/20 [$185.00]
Covington, LA - 10/15/20 [$185.00]
Tifton,, GA - 10/20/20 [$185.00]
Columbus, GA - 10/21/20 [$185.00]
Macon, GA - 10/22/20 [$185.00]
Lawton, OK - 11/03/20 [$185.00]
Ardmore, OK - 11/04/20 [$185.00]
McAlester,, OK - 11/05/20 [$185.00]
El Dorado,, AR - 11/11/20 [$185.00]
Texarkana, TX - 11/12/20 [$185.00]
Arkandelphia, AR - 11/13/20 [$185.00]
Brookhaven, MS - 01/23/20 [$325.00]
Gulfport, MS - 01/25/20 [$325.00]
Baton Rouge, LA - 02/14/20 [$325.00]
Jackson, MS - 03/13/20 [$325.00]
Birmingham, AL - 07/18/20 [$325.00]
Hot Springs,, AR - 08/21/20 [$325.00]
Fayetteville, AR - 08/29/20 [$325.00]
Shreveport, LA - 02/07/20 [$325.00]
Lafayette, LA - 02/22/20 [$325.00]
Tupelo,, MS - 04/17/20 [$325.00]
Searcy, AR - 05/01/20 [$185.00]
Ardmore, OK - 05/16/20 [$325.00]
Little Rock,, AR - 10/03/20 [$325.00]
Covington, LA - 02/13/20 [$185.00]
Gulfport, MS - 02/20/20 [$185.00]
Baton Rouge, LA - 03/31/20 [$185.00]
Corinth, MS - 04/15/20 [$185.00]
Florence,, AL - 04/16/20 [$185.00]
Clinton, MS - 06/11/20 [$185.00]
Monroe,, LA - 06/12/20 [$185.00]
Hammond, LA - 07/09/20 [$185.00]
Madison, AL - 08/14/20 [$185.00]
Ruston, LA - 09/22/20 [$185.00]
Searcy, AR - 12/03/20 [$185.00]
Jonesboro, AR - 12/12/20 [$185.00]
Cancellation Policy Acknowledgement
*
I have read and understand
Lagniappe Seminars Cancellation Policy
Offline Registration Form