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* 1. What is your first and last name, as you would like it to appear on your certificate?

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* 2. Please provide the e-mail address where you would like your certificate to be e-mailed. 

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* 3. What is the title of the LSVT Global community On Demand webinar that you viewed?

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* 4. What is the date that you viewed the LSVT Global community On Demand webinar?

Date

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* 5. Do you attest to viewing the webinar for the full duration?

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* 6. Please list 3 items that you learned from the webinar. 

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* 7. Please provide the name of your discipline, whether a student or professional (e.g. speech-language pathology, physical therapy, occupational therapy), so that your certificate can be formatted appropriately. 

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* 8. Please rate the audio and visual quality of the webinar.

  Excellent Good Acceptable Poor Horrible
Audio Quality
Visual Quality

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* 9. If you have any suggestions for future webinar topics we would love your input! Please provide any suggestions below.

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* 10. If you have any additional comments, please include them below.

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* 11. If you have a question for an LSVT LOUD or LSVT BIG Faculty Instructor, please write it below and include your contact info (name, phone number and/or e-mail address) so we may reach out to you.

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