APPLICATION
First Name
*
Last Name
*
Mobile Phone
*
Email
*
Practice Name
*
Practice Address
*
City
*
State
*
Zip Code
*
Website
Practice Setting (Primary setting where most hours are spent):
*
Please select your answer
If you have a specialty certification please select below. If not, please select N/A
*
OCS
NCS
ECS
GCS
PCS
SCS
CHT
CHT
N/A
Do You Consent to being contacted via email or phone by a PT/PTA program to be a clinical instructor for students?
*
Please select your answer
Do you wish to volunteer time in the UPTA to advocate for the profession?
Please select your answer
What Membership Did You Select?
*
Please select your answer
If you are a non clinician tell us which clinician sponsored you and how you are involved in physical therapy.
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Application:
Physical Therapy
