2024 Camper Application

2024 Practicum Therapist Application
A $200 refundable deposit via check or Zeffy is required before we review your application. The remaining balance is due upon acceptance. Make checks payable to Avanti Therapeutic Projects and use the mailing address on our website. If planning to use our Zeffy site, you will automatically be redirected upon submitting this application.

** Please note that Zeffy is a free site for non-profits. In return they make a suggestion for a contribution at check out, but there is no obligation to do so. Just adjust the amount to $0 or whatever feels most comfortable for you. **
Take Photo*
Full Name*

First NameLast Name
Preferred Phone Number*
Alternate Phone Number
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about the Avanti practicum program?*

Qualifications

This information will assist the review committee in determining if this is a good fit.
Education and degrees*
Professional registration or licensure # and state.*
Brief job description (current job)*
Work experience with dates. You may upload a resume for additional information.*
File Upload: Resume

Cancelof
Briefly identify what continuing education you have completed specific to neurological and/or developmental principles. Please include title and instructor when possible.*

Other Information
What do you hope to learn from this experience? State your goals.*
Please list special interests and/or skills which you might be able to contribute.*

2024 Practicum Therapist Application