Registration – Advancing Your Aquatic Therapy Toolbox Cancel Tuition $300.00 Mail payment to: Juanita Moore Duke University Medical Center Dept. of Physical and Occupational Therapy BOX 3965 Durham, NC 27710 RE: Continuing Education To register a space, please fill out the form below. Please note that boxes followed by ** are required information. First Name: ** Last Name: ** Select: ** PT PTA OA COTA Address 1: ** Address 2: City: ** State: ** Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: ** Home Phone: ** Work Phone: ** Email ** Fax: ** required fields Any personal information that you provide to Duke University Health System, such as your name, address or phone number will be kept strictly confidential and will not be disclosed or sold to any outside organization.