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

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* 1. Last Name:

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* 2. First Name:

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* 3. Email address:

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* 4. Are you a recent graduate?

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* 5. Discipline:

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* 6. Position:

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* 7. Building Name:

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* 8. Building Location - State:

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

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

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

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

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

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* 14. Additional comments:

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

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