Destination Rehab contact form

Thank you for filling out our interest form! You will be contacted soon by someone on our team. We look forward to getting to know you better!

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* 1. Name (first & last)

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* 2. Email

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* 3. Phone Number (with area code)

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* 4. What is your birthday?

Birthdate

Date

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* 5. I want to be involved as a (choose all that apply)

Participant (neurologic condition)

Support team member (family, friend)

Volunteer

Donor

Community Partner

Advisor

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* 6. I would like to be contacted with information regarding (choose all that apply)

Adventure Rehab Camps

Local events (Bend, OR)

One-on-one PT sessions

Exercise/Wellness classes

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* 7. Can you tell us a little about yourself?

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* 8. How did you hear about us?

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* 9. What activities interest you most? (select all that apply)

kayaking

hiking/trail wheelchair

biking

art

exercise/fitness

health education

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* 10. What do you hope to get out of this program? (select all that apply)

increased confidence

social support

improved independence

trying new activities

improved quality of life

health management

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* 1. Name (first & last)

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* 2. Email

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* 3. Phone Number (with area code)

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* 4. What is your birthday?

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* 5. I want to be involved as a (choose all that apply)

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* 6. I would like to be contacted with information regarding (choose all that apply)

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* 7. Can you tell us a little about yourself?

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* 8. How did you hear about us?

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* 9. What activities interest you most?﻿ (select all that apply)

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* 10. What do you hope to get out of this program? (select all that apply)

* 9. What activities interest you most? (select all that apply)