Application Process: Send completed application
with payment to
| Neuro-Rehabilitation Training & Education |
| P.O. Box 153130 |
| San Diego, CA 92195 |
Applicants who meet the stated requirements will be accepted in the order received. Please check course applying for.
| Course | Dates | Location | |
| __ | Neuro-IFRAH™ Certification course...: |
____________________ | ________________________ |
| __ | Introduction to Neuro- IFRAH™...: |
____________________ | ________________________ |
| __ | Resolving Shoulder Impairments and Improving Function |
____________________ | ________________________ |
| __ | Assessment and Management of Functional Gait: Walking for Life |
____________________ | ________________________ |
| __ | Function in Upright Postures | ____________________ |
________________________ |
| Name: ____________________________________ |
| Profession:_______________________________ |
| Mailing Address:__________________________ |
| City:_____________________________________ |
| State:____________________________________ Zip Code:________________ |
| Phone:___________(H) _____________________(Cell) ______________ |
| (W) _______________ |
| e-mail:___________________________________ |
| Professional Schools Attended:_______________________________________ |
| Date Graduated:______________________ |
| Current Postition:____________________ |
| Hours of direct patient contact per week:________________________ |
| Type of facility:________________________ |
| Total years of experience with hemiplegia:________________________ |
| If paying by check please make check payable to Neuro-Rehabilitation Training & Education |
| If paying by credit card please fill out section below. |
| Type of card circle:
Visa Mastercard
American Express |
| Amount to be billed to credit card $_____________________ |
| Credit Card # _______________________________________security # on back __ __ __ |
| Expiration Date:____________________________________________ |
| Name on Credit Card:______________________________________ |
| Billing Address: ___________________________________________ |
| Signature: ___________________________________________ |