ASOP Casting Instructor Application 2024

Casting Instructor Application

Only active ASOP or NBCOS members will be considered.
Todays Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*

Area CodePhone Number
Personal E-mail*
Employer Name (Clinic/Hospital/Office)*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Work Phone Number*

Area CodePhone Number
Work E-mail
example@example.com
Work Fax #

Area CodePhone Number
Practice Manager Name

First NameLast Name
PROFESSIONAL CREDENTIALS Select all that apply:

ROTATCOPE-CPA-CMDOTCMAXray TechRN/NPLPNOther
1. Check box if this applies to you

I have been casting over two years
2. Check box if this applies to you

I have been casting over 5 years
3. Check box if this applies to you

I apply braces in my office
4. Check box if this applies to you

I apply Exos braces in my office
5. Check box if this applies to you

I apply water proof casts using Aquacast in my office
6. Check box if this applies to you

I have my own cast saw and casting tools I can use on a weekend
7. Check box if this applies to you

I have trained students in casting before
8. Check box if this applies to you

I feel comfortable instructing others in short arm, long arm, thumb spica, ulnar gutter and short leg casting.
8. Check box if this applies to you

I feel comfortable instructing others in all types of OrthoGlass roll extremity splinting used in ER's and Urgent care facilities to include Sugar Tong, Wrist, Long Arm, Thumb Spica and Posterior Short and Long Leg Splints.
Should be Empty: