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
Outpatient Private Practice
Home Health Part A
Home Health Part B
Outpatient Hospital
Pediatrics
Acute Care
Sub Acute Care
Skilled Nursing Facility
Academia
No elements found. Consider changing the search query.
List is empty.
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
Yes
No
No elements found. Consider changing the search query.
List is empty.
Do you wish to volunteer time in the UPTA to advocate for the profession?
Please select your answer
Yes
No
No elements found. Consider changing the search query.
List is empty.
What Membership Did You Select?
*
Please select your answer
Physical Therapist
Physical Therapist Assistant
Student
Non Clincian
No elements found. Consider changing the search query.
List is empty.
If you are a non clinician tell us which clinician sponsored you and how you are involved in physical therapy.
Privacy Policy
Cookie Policy
Member Agreement
Application: PT Assistant
