Self Study Workshop Registration Form

REGISTRATION

The Self-study Workshop is presented by the Department of Accreditation at the American Physical Therapy Association.

The Purpose of the Self-study Workshop is to prepare faculty and program administrators to develop a Self-study Report and host an on-site visit.

To Register: Complete information and submit.

COST: The workshop is FREE of charge.

Travel, hotel arrangements and meals are your responsibility. Additional information provided at the end of the registration.

1. Please indicate which workshop you plan to attend; no late registrations will be accepted.

Please indicate which workshop you plan to attend; no late registrations will be accepted. June 13-14, 2010: Boston, MA- Registration deadline May 21, 2010

February 16-17, 2010: San Diego, CA- Registration deadline January 25, 2010

2. Please indicate your affiliation:

Please indicate your affiliation: Accredited PT

Accredited PTA

Developing PT

Developing PTA

On-Site Reviewer

3. NAME OF INSTITUTION

NAME OF INSTITUTION

4. INSTITUTION ADDRESS

INSTITUTION ADDRESS Department/School Name
Street Address 1
Street Address 2
City, State, and Zip Code

5. CONTACT INFORMATION

CONTACT INFORMATION Name and Credentials
Title
Preferred First Name for Name Badge
Email Address
Phone Number