Educational Needs Assessment Form
PROFESSIONAL CONTINUING EDUCATION COURSE
PELVIC REHAB MANUAL ASSESSMENT & TREATMENT TECHNIQUES
Name:
Address (full address and zip code):
Email:
Phone #:
Professional License/Degree
Work & Continuing Education History (# of years):
Current work and areas of specialty:
Desired area of practice:
Goals for upcoming course:
Location Preference
Please indicate which location you are interested in registering for. If you have a plan A and B pending COVID-19 travel advisories, please indicate below in comments section.
Clear selection
If you selected Distance Learning- Interactive above (participant or host site), please indicate who you will be participating with, or what satellite location you are interested in attending.
Learners with special needs accommodation request:
Additional Comments
Please indicate if you are interested in hosting a satellite location, and/or if you have taken PRMATT or PF1 and are interested in TA'g. Any additional information you would like to share.
Submit
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