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!

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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. Age range

under 21

21-39

40-64

65+

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

Participant

Support team member (family, friend)

Volunteer

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* 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

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

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* 8. How did you hear about us?