Application - Waiver Request | Neonatal Touch and Massage Certification

Name*

First Last

Profession*

ASHA ID #*

License Number*

Professional Credentials*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Phone Number*

Phone Type*

Work
Home
Cell

Email 1*

Email Type*

Work
Home

Email 2*

Email Type*

Work
Home

Where do you plan to attend the Hands-On training?*

Virtual Hands-On Training opportunities fill up quickly so if the date you choose is full we will contact you to find your next preference of dates! When making your date/location selection, please keep in mind the 15 hours of On-Line Education for Phase II must be completed 10 days prior to the Phase III Hands On Training. Be sure to schedule yourself ample time to complete this portion of NTMC!

Are you an employee at the hospital that is hosting NTMC at the location you identified above?*

Yes
No

Will 3 or more employees from your hospital be attending NTMC at the same location - which qualifies you all for a 10% discount?

Yes
No

If you checked YES above, please list names of others below.

How do you plan to pay for NTMC?

Where do you plan to attend the Hands-On training?

When making your date/location selection, please keep in mind the 16 hours of On-Line Education for Phase II must be completed 10 days prior to the Phase III Hands On Training. Be sure to schedule yourself at an NTMC date/location that allows ample time to complete this portion of NTMC! Virtual Hands-On Training opportunities fill up quickly so if the date you choose is full we will contact you to find your next preference of dates!

How did you hear about the NTMC?*

Other

How did you hear about us?

Pediatric Employment History

Current Job Title*

Current Employer*

Employer Phone*

Employer Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Years of Employment (i.e., 1998 – 2003)*

Full Time or Part Time*

Full Time
Part Time

Supervisor's Name*

Supervisor's Title and Credentials*

Supervisor's Email Address*

Past Employer Name

Past Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Years of Employment (i.e., 1998 – 2003)

Full Time or Part Time

Full Time
Part Time

Waiver Request - I am requesting a waiver of the Neonatal Touch & Massage Certification requirement of 1000 clinical hours in the Neonatal Intensive Care Unit or Special Care Unit for the following reason(s). Check all that apply:*

I work with other NTMC Professionals
I provide early intervention for former preterm infants
I work for the hospital hosting NTMC
I participate in a NICU/high risk infant follow up clinic
I work in a NICU/SCN but have not met the 1000 hours requirement at this time
I work in a Level 1 NICU with infants diagnosed with NAS/OED/OEN

Other- Please describe in detail any relevant experiences that may contribute to your acceptance as an NTMC Candidate!

Upon submission your request will be reviewed by Creative Therapy Consultants

Verification*

I verify that I am a neonatal Occupational Therapist, Physical Therapist, Speech Language Pathologist or Registered Nurse, I am in good standing with my professional licensing body, and have a current professional license.

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Application – Waiver Request

Please fill out the form below. If you are unable to complete the online application, please email us here.

Pediatric Employment History