Registration Form for Ursa Classes

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	Tuition - 2008 Classes 2 1/2 day class $600 - 18 contact hours Sacramento CA 2 1/2 day class $900 - 18 contact hours Edmonds WA 2 1/2 day class $700 - 18 contact hours Reno NV and Farmington CT All enrollees must possess the statutory authority by Licensing, Registration or Certification to apply the techniques learned. DO MD PT OT LMT LMP ATC PTA PA DC DDS ND RN Osteopathic Physicians, Medical Doctors, Physical Therapist, Occupational Therapist, Licensed massage Therapist/Practitioners, Athletic Trainers, Physical Therapy Assistants, Physician Assistants, Chiropractors, Dentists, Nurses, and others that have the statutory authority to apply the techniques learned. click here for Printer Ready Form Ursa Foundation P.O. Box 1447 Edmonds, WA 98020-1447 206 546 3676 REGISTRATION FORM Name:_______________________________________________________ Profession (Circle) DO MD PT OT LMT LMP ATC PTA PA DC DDS ND RN Other _________ License or Registration #____________________________ Work Address:_______________________________________________________ Home Address:________________________________________________________ _______________________________________________________________ _______________________________________________________________ Phone:_( )_________________________________________ Email_________________________________ Address__________________________ WORK: ( ) _____________ FAX ( )____________________ HOME: ( )______________ HOME FAX ( )______________ Course Title:______________________________________________________ Course Date:______________________________________________________ Course Location___________________________________________________ Deposit ______________ $100.00 non-refundable/non-transferable deposit is required to reserve a place on the class. A deposit of $100. is required to hold a place on each class. The deposit is non-refundable/non-transferable. The tuition balance is due one month prior to the course date. Make your check payable to Ursa Foundation and mail with your registration to PO Box 1447, Edmonds, WA 98022 - 1477. We do not accept credit cards.