Registration Form

Foundations in Manual Therapy: Voice and Swallowing Disorders Registration

Please complete this entire form, as applicable.
City and Dates of Seminar Attending
This class is pre-approved by ASHA and NCBTMB (massage therapists). If you are a PT or OT, and are requesting CEUs for this course, please fill in the profession and State. PT and OT CEUs must be requested well in advance of the class and not all are available. Contact wfritzpt@gmail.com for details.
Profession and State
Do you wish us to submit to the ASHA registry on your behalf?

YesNo
Item numbers 1-11 are for SLPs who wish us to submit to ASHA on their behalf. The information should reflect what is recorded on the ASHA registry.
1. If you are an SLP/SLT, what is your ASHA number?
2. Last name (Surname)
3. First name (Given name)
4. Address on record with ASHA
5. Address (Apt., Suite)
6. Address (additional)
7. City on record with ASHA
8. State/Province on record with ASHA
9. Zip/Postal Code on record with ASHA
11. Country on record with ASHA
10. E-mail on record with ASHA
example@example.com
All applicants should complete the entire section below.
Full name and professional credentials as you wish them to appear on your course Certificate of Completion
Business E-mail (for inclusion on the free Clinician Directory)
example@example.com
Business Phone Number
Business Name and Street Address
City
State, Province, or Region
Zip/Postal Code
Business Country
Personal E-mail (Essential, as work email servers will often block incoming emails from commercial senders. NOTE: THIS IS THE EMAIL ADDRESS THAT WILL BE SUED TO ENROLL YOU IN THE MANDATORY 2-HOUR ONLINE COURSE.)
example@example.com
Personal Cell Phone Number
Please enter a valid phone number.
Do you have any special needs or requests?
What do you hope to learn from this class?
If you have any comments, please note them here. If paying by check, complete this form and mention your method of payment here. If you would prefer to pay by credit card via phone, complete the form and notate your request for us to call you here.
After payment and this registration form are received, Foundations Seminars will email you within 48 hours with additional information. If you are registering for the Introductory Voice and Swallowing Disorders class, you will be required to complete a 2-hour online prerequisite course, which is distributed 2-3 weeks before the start of the in-person workshop. Links to the hands-on manual and venue details will also be sent at that time.

If you have not yet made payment, please do so from the website or contact us at wfritzpt@gmail.com or 585-244-6180 (text or call).
Your signature is required. Please sign and click the green "Continue" button. A copy of this form will be emailed to you.

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Foundations in Manual Therapy: Voice and Swallowing Disorders Registration

Item numbers 1-11 are for SLPs who wish us to submit to ASHA on their behalf. The information should reflect what is recorded on the ASHA registry.

All applicants should complete the entire section below.