Registration Form

• Ticket Name

  Full Name*

  Email Address*

  Phone Number*

  Professional Designation* Physical Therapist (PT) Occupational Therapist (OT)

  Present Employer*

  Supervising Manager Name*

  Supervising Manager Email*

  Emergency Contact Name*

  Emergency Contact Phone Number*

  Name and credentials as you would like them to appear on the certificate*

  Degrees obtained with graduation years*

  Clinical Work* Acute Care Inpatient Rehabilitation Skilled Nursing Facility Long-Term Care Facility Outpatient Clinic Home Health Care Private Practice School System Adult Day Care Other

  You are required to hold malpractice liability insurance which will cover you during your participation in the course. Please upload proof of your current personal or employer malpractice liability insurance coverage showing date of expiry.*

  You are required to hold a license to practice during your participation in the course. Please upload a copy of your current professional license registration showing date of expiry.*

  * Agree that you are committing to participate fully in all days of the course

  * Agree that you have access to treating a minimum of two stroke patients every week throughout the course

  * Agree that you will be able to participate in all the patient treatment and physical requirements of the course (e.g. transferring severely impaired clients, working on classmates, having classmates work on you, etc.)

  Subscribe for email communications and course updates

  Add anything that you feel would be important for the course organizer or instructors to know