Home Study Application  
 

MotherMassage® : Massage During Pregnancy Home Study Course APPLICATION

Please complete this form. When you hit the 'Send' button below the form will be emailed.
Upon acceptance of your application, you will receive an invoice for $130.45 (International customers: $136.45), which includes shipping.
Upon receipt of payment, the home study course will be shipped to you.

Personal Information [* indicates required field]
First Name*
Last Name*
Address line 1*
Address line 2
City*
State*
Zip*
Country
Home Phone*
Work Phone
Email*
 
Massage Education
Name of School Year
Address line 1
Address line 2
City
State
Zip
Phone
Are you licensed?Yes No
Year of license
Are you NCBTMB certified?Yes No
Year of certification
Florida Licensees Only: License Number
 
DISCLAIMER*:
I acknowledge and accept that this home study program is not a hands-on instruction course and does not grant me professional certification as a prenatal massage therapy specialist. I agree not to represent myself as a prenatal massage therapy specialist or expert and release Elaine Stillerman, LMT and MotherMassage (R), her agents, representatives and publisher of any claims that may be made against me.
Yes No