This survey is to collect information about our therapy teams and their involvement and interest in professional associations.

* 1. Last Name:

* 2. First Name:

* 3. Email address:

4. Are you a recent graduate?

* 5. Discipline:

6. Position:

7. Building Name:

9. Please specify to which professional associations you belong: (Select all that apply)

10. Please specify to which section or interest group you belong: (Select all that apply)

11. If you currently hold office in a professional association please complete the following:

12. If you previously held office in a professional association please complete the following:

13. In what activities have you participated through your professional association: (select all that apply)

14. Additional comments:

15. Would you like to receive ongoing updates and be included in future RehabCare Advocacy Network activities?

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