Name and credentials(Required) Email(Required) Shipping address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Name of course you're teaching(Required) Number of students enrolled in the course(Required)When does your course end? MM slash DD slash YYYY This course is for… Future SLPs (adult-based) Future SLPs (pediatric-based) Future OTs or OTAs Future PTs or PTAs What kinds of resources would you like us to include in the packet? (Select up to 5)(Required) Aphasia Brain Injury Dementia Dysphagia Motor Speech/Dysarthria/Apraxia Parkinson’s Stroke Visual Impairment/Neglect Voice What kinds of resources would you like us to include in the packet? (Select up to 5)(Required) ADLs Balance Bowel/Bladder Brain Injury Chronic Pain Dementia Fall Risk Home Modifications Mental Health Nervous System Conditions Orthopaedics Spinal Cord Injury Stroke Visual Impairment/Neglect What kinds of resources would you like us to include in the packet? (Select up to 5)(Required) Aging Arthritis Balance Brain Injury Cardiovascular Disease Chronic Pain Fall Risk Nervous System Conditions Orthopaedics Spinal Cord Injury Sports and Exercise Stroke What kinds of resources would you like us to include in the packet? (Select up to 5)(Required) Phonology Fluency CAS Autism Brain Injury Language Development AAC Pragmatics Birth-3 Multilingualism Deaf/HOH Feeding and Swallowing Literacy Pediatric Voice Would you like Therapy Insights to provide a 30 or 60 minute Zoom presentation (select from a variety of topics)(Required) Yes, please! No, thank you. Please select the topic:(Required) For students: Diving Into the Field with Coordination and Grace: Resumé writing tips, CFY interview tips, and why you’ll never be boxed in when you have a passion for learning Health Literacy: Eliminate the phrase “non-compliant” and empower informed patient choice (for students who want to work with adults) Let’s Co-Treat: 20 easy-to-implement and meaningful interdisciplinary (PT/OT/SLP) treatment ideas (beyond standing and doing a card game (for students who want to work with adults) Trans-disciplinary Care: How clinicians can build bridges for nursing, dining, and activities staff to be therapy allies (for students who want to work with adults) Would you prefer 30 minutes or 60 minutes?(Required) 30 minutes 60 minutes Anything else we need to know?EmailThis field is for validation purposes and should be left unchanged.