Early Professional Special Interest Group

Early Professional Special Interest Group

APTA North Carolina
Name*

First NameLast Name
Email*
example@example.com
Date of Graduation*

MonthDayYear
Date
School Attended*
Professional Designation*
Current Organization*
APTA NC Region*
Current Practice Setting*

Home HealthInpatient/ Acute CareInpatient/ RehabilitationOutpatient (hospital based)Outpatient (private practice, or other)School SystemSkilled Nursing Facility/ Long-term Care/ Short-term RehabOther
Areas of Expertise or Interest*

AquaticsCardiovascular & PulmonaryEducation/ Admin/ Policy/ ResearchGeriatricsNeurology/ VestibularOncologyPediatricsSportsWomen's Health/ Pelvic HealthWound Management
Are you interested in being involved with a committee?*

Communications: Maintain social media, website, newsletters and other marketing campaignsMembership: Recruit, retain, and re-engageEducation: Oversee continuing education, journal clubs, or other offerings of interestProfessional Development: Direct activities for enhanced professional growthI am not interested in being involved with a committee
If you are interested in being involved with a committee, would you be interested in chairing or being a committee member?*

ChairCommittee ChairI am not interested in being involved with a committee
Would you be willing to serve on the Executive Board (Chair, Vice Chair, Secretary, Treasurer)?*

YesNoMaybe, I would need to know more!
What are you hoping to get out of your membership with the EP SIG? What are some goals that you need help achieving or areas in which you need support? What concerns do you have? What resources do you need?*
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