Home >> Registration Form for Ursa Classes

Registration Form for Ursa Classes

Tuition

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.

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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.

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