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Fax: (318) 340-9865
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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
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Professional Credentials
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PT
PTA
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Professional Credentials Other
License #
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License Renewal Date
Month
Month
Jan
Feb
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May
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Jul
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Day
Day
1
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Year
Year
2014
2015
2016
2017
2018
2019
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2026
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2028
2029
Address
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Address Line 2
City
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State
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Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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Iowa
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Kentucky
Louisiana
Maine
Marshall Islands
Maryland
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Michigan
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Mississippi
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Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
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Phone #
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Work #
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Cell #
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Email
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Employer
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Seminar
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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
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I have read and understand
Lagniappe Seminars Cancellation Policy