|
|
||||
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
The tuition balance is due in full one month prior to the course date.
The deposit is non-refundable/non-transferable.
The tuition balance is due
one month prior to the course date.
Make your check payable to the Ursa Foundation.
Mail check with the registration to
P.O. Box 1447, Edmonds, WA 98020 – 1447
We do not accept credit cards.
Linda N. Mazzuca, Executive Director
206 546 3676
lindamazzuca@comcast.net