Colorado Center for Healing Touch, Inc

INDEPENDENT CLASS FEE REPORT

Please send all class materials to HTP within two weeks.One Class Fee Report per workshop.

Send this form and all items above to: (preferred)

or mail to: Healing Touch Program, 15439 Pebble Gate, San Antonio, TX 78232

Class Title: / Level:
Class Dates: / CE Hours:
City: / State:
Country: / Zipcode:
Instructor: / Signature / Change in COI Status
Instructor 2: / Signature / Change in COI Status
Coordinator: / Signature

Check Box for Digital Signature.Signature indicates acceptance of and adherence to the HTP Instructor and Coordinator Guidelines, and to the Terms of the Coordinator Agreement. If either of the Instructors indicates a change in their Conflict of Interest (COI) Status they must complete and attach new Conflict of Interest Disclosure and Resolution forms.

Send Certificates to:

Address:
City: / State:
Country: / Zipcode:
Please complete each category below
Type of Participant / # of Participants / Per-Student Fee / Total
Regular Tuition (Includes Scholarships) / $75 to HTP / $
HTPA/AHNA Member / $65 to HTP / $
Repeat Student / $50 to HTP / $
Full Time Student / $50 to HTP / $
Non Paying Student* / $15 for CE Certificate / $
Introduction Class Certificates / $10 to HTP / $
Helpers/Coordinator Certificates / $0 / $
More than 2 Helpers $15 per certificate / $15 each / $
Total Participants / Total Due / $
Number of Nurses
Number of Other Healthcare Professionals
*Classes that have made prior arrangements with HTP and have an Instructor Agreement Addendum

Class Packet ChecklistPayment Information: Please send total amount due to HTP

Send this form and all items above to: (preferred)

or mail to: Healing Touch Program, 15439 Pebble Gate, San Antonio, TX 78232

Coordinator Agreement / Payment Type
Choose One / Amount
Class Roster / Check
Class Fees / Third Party Payee / Name:
Address:
Phone:
Summary Evaluation / Credit Card / MC / Visa / Discover
Participant Evaluations
1 per certificate requested / Card Number / Exp. / CVV / Signature
Confirmation letter
w/ ANCC required disclosures / Digital Signature / Check here for digital signature
Brochure
w/ required ANCC statement / Authorization / Date / Initials

Class Code

Send this form and all items above to: (preferred)

or mail to: Healing Touch Program, 15439 Pebble Gate, San Antonio, TX 78232