Application | Neonatal Touch and Massage Certification

Profession*

ASHA ID #*

License Number*

Professional Credentials*

Email 1*

Email 2*

Preferred Phone Number*

Where do you plan to attend the Hands-On training? (Nurses attend Day 1, Therapists attend Day 1 &2)*

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 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?

NICU or SCN Employment History

Current Job Title*

Place of Employment*

Employer Phone*

Nursery Level (II, III, IV)*

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

Supervisor's Name*

Supervisor's Title and Credentials*

Supervisor's Email Address*

Prior Employment

Prior Place of Employment

Nursery Level (II, III, IV)

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

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Fill out the form below or click here to download a PDF application to print and mail or email in.

Certification Application - 2024

NICU or SCN Employment History

Prior Employment