Occupational Therapy for Native Americans (OTNA) Network Form

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This information is being gathered by Maggie Deforge, Chair of OTNA. Other members of OTNA will see your email address when emails are sent to the group. Other information will only be used by OTNA leadership, unless we explicitly obtain your permission to share with another person within or outside of the network.

Last Name *

First Name *

OT or OTA? *

OTA

OT Student

OTA Student

Other:

Briefly describe your tribal affiliation(s); if none, write N/A *

Email address *

Current State *

Current City *

Current employer and/or practice area *

Do you currently work with a predominantly Indigenous patient population? *

Yes

Are you willing to be contacted about accepting a level 2 fieldwork student? *

Yes

Maybe

Tell us a little bit about yourself and your OT interests! *

Submit

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