Myofascial Release Network

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To be a part of the MFR Network please provide us with the information below. You can do so by fax or with a phone call. Please call (303) 440-3359 with the information below.
If you would like to fax us your order, please fill out the form below and print the document. Send the printed and completed form to: MFR Network (303)545-9527. To confirm receipt of the fax, or if you have questions, please call (303) 440-3359, or email mfr@somapt.com.

LISTING INFORMATION:
First Name:
Last Name:
Credentials (MT, OT, PT, etc.)
Email Address:
Website:
Office Phone:
Cell Phone:
Fax:
Address:
Address 2:
City:
State:		Zip:
BILLING INFORMATION:
Credit Card Type:	MC Visa Discover
Card Number:
Expiration:
Name on Card:
Billing Address :
Billing Address 2:
Billing City :
Billing State:		Zip:

Courses Completed:(Check All that Apply, See Rating Scale below)

Novice Intermediate Advanced Expert

Novice:

Myofascial Release I OR
Myofascial Mobilization OR
Pediatric Myofascial Release OR
Equine Myofascial Release
Fascial Pelvis Myofascial Release

Intermediate:

All Novice Skills, PLUS:
Myofascial Release I
Myofascial Unwinding
Myofascial Release II
Cervical-Thoracic Myofascial Release
OR Myofascial Rebounding
OR Skill Enhancement Seminar

Advanced:

All Intermediate Skills, PLUS:
Cervical-Thoracic Myofascial Release
Myofascial Rebounding
Skill Enhancement Seminar
Advanced Myofascial Unwinding
Minimum of 1 year of experience using MFR exclusively

Expert:

All Advanced Skills, PLUS:
Myofascial Release III
Minimum of 2 years of experience using MFR exclusively

Your credit card will reflect a one year listing fee.

Individual Profile	Logo or Picture	Address	Credentials / Skill Level
($325 per year)		Therapy on the Rocks 676 North Highway 89A Sedona, AZ 86336 Phone: (928) 282-3002 Fax: (928) 282-7274 sedona@myofascialrelease.com www.myofascialrelease.com	John F. Barnes,PT Advanced MFR Practitioner
Two Therapists	Logo or Picture	Address	Credentials / Skill Level
($450 per year)	Mark F. Barnes, PT, MPT, DPT Brian Barnes, MT	Barnes Myofascial Release 2400 Spruce, #201 Boulder, CO 80302 Phone: (303) 440-3359 boulder@myofascialrelease.com www.somapt.com	Expert MFR Practitioners

Once you have complete the sign-up form, you will receive an email that your registration has been received. If you would like to post a picture, email mfr@somapt.com with your image file as an attachment. All Logos and Photos must be no larger than 100X100 Pixles, and with a file size no larger than 9k. Images must be in either GIF or JPEG format with the appropriate suffix at the end of the name. (i.e. .jpg or .gif). If you have any questions, please call(303) 440-3359, or email mfr@somapt.com.