Section 1 | Basic Information

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Partner Information (optional)


Section 2 | Terms and Policies

Please review the following policies, and type your name in the signature box to agree to all.
I agree to comply with PIP's Tdap Policy.


I have read and agree to the terms and conditions set forth in the Release of Liability.

I understand that the $25 deposit is non-refundable. I agree to pay the remainder of my program fee in full before the first meeting.