Name *

First Name

Last Name

Phone

(###)

###

####

What is your DMI Level?

Level A

Level B

Level C

Level D

Which of the following best describes your qualifications? (Select all that apply) *

Physical Therapist (PT)

Physical Therapy Assistant (PTA)

Occupational Therapist (OT)

Occupational Therapy Assistant (OTA)

Other (please specify in additional comments)