Certificate Enrollment – EcoArts Therapy

Name*
First Last
Email*
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Phone*
Best time to call you*
Should we need to contact you or your request to be contacted by phone what is the best time and day to reach you? Please include your time zone.
Postal Mailing Address*
How did you find us?*
Note: If you were referred by an EcoArt/PNC Student please enter their full name or if you have a discount code enter it here.

Are you a Project NatureConnect Student?*
- Yes
- No
Certificate/Degree*
Please enter the current PNC certificate and/or degree you are working on.
Have you completed Eco 500 (B) with PNC?*
- Yes
- No
Have you paid for Eco 500 (B) with PNC?*
- Yes
- No
- Scholarship/Work Study Student

Size of Class*
Every attempt will be made to put individuals in the group size they select. Please note it may not always be possible to put you in a smaller or larger course.
Number of hours per week you can dedicate to your coursework:*
Typically courses take 1-3 hours of work. Some may require more or less depending on the pace at which you read, complete your activities, and respond to others.
Estimated timeframe you would like to complete your studies.*
- 1 Year
- 2 Years or less
Special Needs
Please briefly describe any special needs or requests you may have that may affect your coursework. (I.E. extra help with technology, taking a planned vacation, etc.)

Bio*
Please briefly describe yourself and your interests. (500 characters maximum.)
Comments/Suggestions:
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