Registration via Purchase Order

ChildLight Education Company

53 Washington St., Suite LL100

Dover, NH 03820

School / Organization Information *

School / Organization Name
Street Address
City	State / Province
Postal / Zip Code	Country

Billing address, if different from above

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Billing Contact *

First Name Last Name

Billing Contact Email Address *

Billing Contact Phone Number *

Area Code Phone Number

Please select training you wish to attend. *

Please select start date of the training. *

Month Day Year Date Picker Icon

City and State of Training Location *

1. Name *

Position / Grade *

Cell Phone Number *

Email Address *

2. Name

Position / Grade

Cell Phone Number

Email Address

3. Name

Position / Grade

Cell Phone Number

Email Address

4. Name

Position / Grade

Cell Phone Number

Email Address

5. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

6. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

7. Name

Position / Grade

Cell Phone Number

Email Address

8. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

9. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

10. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

11. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

12. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

13. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

14. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

15. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

16. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

17. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

18. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

19. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

20. Name

Position / Grade

Cell Phone Number

Email Address

example@example.com

Please check box below if you will be paying by Credit Card. Invoice will be submitted via email to Billing Contact above to be paid online upon receipt of invoice.

Credit Card

If the registrant is part of the ChildLight 95hr RCYT Program, please enter their 95hr promo code here or any other applicable promo code (only one may be used at a time):

Purchase Order Terms

If registering with a purchase order, please provide the purchase order number and upload your purchase order below as required.

The billing contact provided will be emailed an invoice upon approval of the purchase order within 3 business days.

For all multi-day training purchase order registrations, please add a $25 processing fee for 1-2 individuals or $50 processing fee for 3 or more. For all one-day workshops, online or on location, please add a $10 processing fee for 1-2 individuals or $25 processing fee for 3 or more.

Purchase Order Terms Agreement

I have read and agreed to the Purchase Order Terms outlined above. Please note that the purchase order processing fee must be included on your purchase order in order to be accepted and processed.

Purchase Order No.

Upload Purchase Order (Required)

How did you hear about us? *

If you are registering another person for a ChildLight workshop or training, by clicking the box below you are agreeing to our terms & conditions on the registrant's behalf.

Registration via a Purchase Order