Neurology Special Interest Group
APTA North Carolina
Name
*
First Name
Last Name
Email
*
example@example.com
Date of Graduation
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
School Attended
*
Professional Designation
*
SPT
SPTA
PT
PTA
Current Organization
*
APTA NC Region
*
Mountain
Capital
Piedmont
Coastal
Current Practice Setting
*
Home Health
Inpatient/ Acute Care
Inpatient/ Rehabilitation
Outpatient (hospital based)
Outpatient (private practice, or other)
School System
Skilled Nursing Facility/ Long-term Care/ Short-term Rehab
Other
Areas of Expertise or Interest
*
Aquatics
Cardiovascular & Pulmonary
Education/ Admin/ Policy/ Research
Geriatrics
Neurology/ Vestibular
Oncology
Pediatrics
Sports
Women's Health/ Pelvic Health
Wound Management
Are you interested in being involved with a committee?
*
Communications: Maintain social media, website, newsletters and other marketing campaigns
Membership: Recruit, retain, and re-engage
Education: Oversee continuing education, journal clubs, or other offerings of interest
Professional Development: Direct activities for enhanced professional growth
I 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?
*
Chair
Committee Chair
I am not interested in being involved with a committee
Would you be willing to serve on the Executive Board (Chair, Vice Chair, Secretary, Treasurer)?
*
Yes
No
Maybe, I would need to know more!
What are you hoping to get out of your membership with the Neuro 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?
*
Submit
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