Destination Rehab Interest 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!
*
1.
Name (first & last)
(Required.)
*
2.
Email
(Required.)
3.
Phone Number (with area code)
4.
Age range
under 21
21-39
40-64
65+
5.
I want to be involved as a (choose all that apply)
Participant
Support team member (family, friend)
Volunteer
6.
I would like to be contacted with information regarding (choose all that apply)
Adventure Rehab Vacation
Adventure Group (meets monthly in Central Oregon)
Local events (Bend, OR)
One-on-one PT sessions
Exercise Classes
7.
Can you tell us a little about yourself?
8.
How did you hear about us?