Please provide the following contact information:
First Name Last Name Street Address Address (cont.) City State Zip Code Profession Home Phone Prof. License # Cell Phone Work Phone Email FAX
FAX
Please select the course you would like to register for, and enter the number of registrants:
MFR1: Myofacial Release Level 1 MFR2: Myofacial Release Level 2 with Craniosacral Therapy INMR1: Integrated Neuromuscular Re-Education, Muscle Energy and Positional Release INMR2: Integrated Neuromuscular Re-Education, Muscle Energy & Positional Release 2 OMTB: Orthopedic Manual Therapy: Back OMTS: Orthopedic Manual Therapy: Shoulder OMTN: Orthopedic Manual Therapy: Neck CST1: Craniosacral Therapy 1 MET: Muscle Energy Therapy PRO: Post Rehab of Orthopedic Injuries Public Health Courses Consciousness Study Group All courses are $199.00 per person. If you are registering for something NOT listed, please enter description here. Course Date: Course Location: Please refer to our calendar for course dates and locations. Number of Registrants / Amount Due: 1 participant for $209.00 2 participants for $369.00 3 participants for $499.00 The stated course fees are only for courses sponsored by Educise Resources Inc. Other sponsors may offer a different fee. Fees are subject to change without notice.
The stated course fees are only for courses sponsored by Educise Resources Inc. Other sponsors may offer a different fee. Fees are subject to change without notice.
Please enter the following payment information for the above Amount Due:
Pay Method: MasterCard Visa Personal Check Employer Check Money Order Cardholder Name: Credit Card #: Credit Card Code: Billing Zip Code: Expiration Date: January February March April May June July August September October November December -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , 2008 2009 2010 2011 2012 Signature: If you are making payment by check or money order, please make it out to Educise Resources, Inc., and send it to Educise Resources Inc. PO Box 1480 Massapequa NY 11758. Completion of the above Signature field authorizes Educise Resources Inc. to process your payment by the Pay Method selected for the total Amount Due..
Please answer the following questions to help us accommodate your needs:
Do you require any special services, information, or equipment? Yes No Do you require hotel or travel information? Yes No Do you require CEU credit for any courses? Yes No Details:
Please let us know if we may share your information:
Educise MAY MAY NOT share my personal information with third parties. Signature: Completion of the above Signature field certifies that you have no personal limitations that may adversely affect my participation in the course. For any technique courses, you will not participate in any practice that may be contra-indicated for your health condition. We respect your right to privacy. Educise will not trade, sell, share, or rent your personal information to a third party without your consent.
Completion of the above Signature field certifies that you have no personal limitations that may adversely affect my participation in the course. For any technique courses, you will not participate in any practice that may be contra-indicated for your health condition. We respect your right to privacy. Educise will not trade, sell, share, or rent your personal information to a third party without your consent.
Please let us know how you heard about us:
I heard about Educise by way of: Internet Direct Mail Employer Publication Other
