Southwest Laser Institute - Secure Registration Form

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Classes for the Laser School will resume in the later part of September 2010 as a schedule will be posted closer to that date.

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Course Calendar

COURSE REGISTRATION FORM

After submitting this form, a Southwest Laser Institute Representative will contact you to complete the registration and payment process.

Please note: Class times and dates are subject to change.

Course & Date of Interest:

(Check All That Apply)

	Certified Laser Technician (CLT) Comprehensive Course:
	June: Friday 18th & Saturday 19th
	Hands-on Training Jan: Wed. 23rd Thurs 24th & Fri 25th

	July: Friday 17th & Saturday 18th
	Hands-on Training March: Wed 21st Thurs 22nd & Fri 23rd

	August: Friday 13th and Saturday 14th
	Hands-on Training March: Wed 18th Thurs 19th & Fri 20th


	Botox & Dermal Filler:
	*Please call our office for November Course availability
	Times and dates are subject to change

	Advanced Botox & Dermal Filler:
	*Please call our office for November Course availability
	Times and dates are subject to change

	Combo CLT/Botox/Dermal Filler
	Please call 602.843.4040 for upcoming classes

	Combo CLT/Botox
	Please call 602.843.4040 for upcoming classes

	Combo CLT/Dermal Filler
	Please call 602.843.4040 for upcoming classes

	Combo CLT & Advanced Injectables
	Please call 602.843.4040 for upcoming classes

Application Date:

Student Contact Informtion:

First Name:
Last Name:

Street Address:

City: State: Zip Code:

Home Phone:
Work Phone:
Mobile Phone:
Email:

Emergency Contact:

Name:
Phone:
Email:

Education & Work History

Level of Education:
Degree/Cert./Lic. Obtained

Are you currently:
Unemployed
Employed
Employer Name:

Work History:

Are you an (Check any or all that apply):
*MD *DO *NMD *DDS *DMD *PA *RN LPN MA
Aesthetician Student
Other:

*(If you are a practicing medical professional you may be asked to supply your current active license number for verification purposes for the injectable courses only. We thank you for your participation.)

How did you hear about SLI?

Mailer	Internet	Conference	TV
Print advertisement:
Referral: Referral Name: Referral School Name:

*A minimum deposit of $250.00 is required to hold a seat for the date indicated. Fully refundable up to fourteen (14) business days prior to registered course date.
**Remaining balances are due fourteen (14) business days prior to course date.

The student understands in regards to payment:

The school does not guarantee job placement upon course completion.
The school reserves the right to reschedule course dates if the number of registrants is not adequate to conduct the course.
The school reserves the right to discontinue the training of any student for unsatisfactory progress, or failure to follow facility conduct expectations.
The school reserves the right to withhold certification to students displaying unsatisfactory academic or practical progress.
The school will not admit student to begin training until full payment of tuition is documented.
The school is not responsible for any laser procedure or protocol not appearing in the training manual or course catalog.

Signature: Your signature will be required.