Name:________________________________________________________________________


Address:______________________________________________________________________________

____________________________________________________________________________

______________________________________________________________________________________

Day phone:______________________ Eve phone _______________
Fax:________________________________
Email____________________________________

__PT __OT __RN __NP __PA __MD __MT* __PTA* __COTA* [*certain conditions apply]

DATES for 2011 Courses: 
Part One: __October 10-15 Part Two: ___October 15-28     Full tuition is due at least 2 weeks before the start of the course. [October 15 is Georgia Lymphedema Awareness Conference]
*A $500 deposit holds your place. Text and more information will be sent on receipt of deposit.
**Tuition for taking Part I and II together: $2500
***Even if Part I and Part II are taken separately, they can be paid for together for $2500
or can be paid for prior to each part: Part I: $1000 and Part II: $2000. Part II must be taken within 12 months of completing Part I.

Enclosed: ___$500 ___$1000 ___$2000 ___$2500 Other: _______________________________

Mail this form and check (made out to Complex Lymphatic Therapy Courses) to:
CLT Courses, Attn: DeCourcy Squire
115 Leyden Street
Decatur, GA 30030
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I understand that during the class participants will practice the various techniques such as compression bandaging and MLD on each other. I declare I have no medical condition that is a contraindication for participating in this class. If I am pregnant or have a medical history of malignancy, deep vein thrombosis, heart or kidney problems, arterial insufficiency, neuropathies, or other conditions that would make compression or increased return of lymph fluids a problem, I will bring written clearance from my physician for participating in the class and will give the instructor adequate information so that any necessary precautions can be followed. I hereby release from liability and agree to hold harmless the Lymphoedema Association of Australia, Judith Casley-Smith, CLT Courses, and DeCourcy Squire for any adverse effects I may experience as a result of the techniques practiced in the class and labs.

Signature:________________________________________________________________ Date: ____________________
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PTAs and COTAs only:
As a PTA or COTA, I understand that my certification in Complex Lymphatic Therapy is contingent on my practicing only under the supervision of a PT or OT who is also certified in Complete Decongestive Physiotherapy/Complex Lymphatic Therapy through a program which meets the minimum standards set by the Lymphology Association of North America (LANA).

Signature: __________________________________________________________________ Date:___ __________________

Please include a copy of your supervising PT or OTs certification.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Massage Therapists:
I have completed 500 hours of training as a massage therapist at an accredited school, am certified and/or licensed in the state in which I practice, and have had at least 12 credit hours of course work in human anatomy, physiology and/or pathophysiology from an accredited university or college. [copy of transcript enclosed]

Signature: __________________________________________________________ Date: _____________________________