2022 Physician Assistant / Physical Therapist Application for the Healer's Art FDW Training

2022 Physician Assistant/Physical Therapist Application for the Healer’s Art FDW Training

1. Name and Education History *This question is required.

First Name
Last Name
Degree(s)
School Attended
Year of Graduation
License #
State of Issue

2. School where you will teach The Healer's Art *This question is required.

School Name
Address
City
State, Zip
Country

5. Certification *This question is required.

6. Professional Position *This question is required.

University or School
Academic Title
Professional Role
Years in Position

Professional Position (if more than one held concurrently)

University or School
Academic Title
Professional Role
Years in Position

7. Work Contact Information *This question is required.

Name
Address
City, State, Zip
Country
Work Phone
Work Fax
Work Email

8. Home Contact Information

Address
City, State, Zip
Country
Home Phone
Cell Phone
Home Email

9. Which is your preferred email? *This question is required.

Work
Home

10. How did you hear about The Healer's Art? *This question is required.

11. What courses do you teach at your school? *This question is required.

12. When do you plan to implement The Healer's Art curriculum?

Start Date

13. What is the student audience at your school? *This question is required.

14. What institutional support do you have for this plan?

Administrative
Dean or Dept. Head
Curriculum Committee
Financial Resources

15. What do you anticipate is the greatest obstacle you may encounter in implementing this program?

16. Approximately how many students are in each class at your school? *This question is required.

17. How do you think that The Healer's Art will serve your students, i.e. what are their unmet needs? *This question is required.

18. What draws you personally to teaching this course? Please describe briefly. *This question is required.

19. What experience do you have leading small groups or workshops? Please describe. *This question is required.

20. Please tell us one way that being in the PA profession has enriched your life. *This question is required.

21. In preparation for the on-site training, do you have any health care needs our staff should know about? Please describe:

22. Is there anything else you would like us to know?

CME credit information for this workshop will be forthcoming.

CANCELLATION & REFUND POLICY: A deposit of $300 is due at time that your application is accepted. The balance is due by June 15, 2022. A full refund of deposit (less processing fee of $25) will be issued for cancellations on or BEFORE July 1. Cancellations after July 1 will forfeit deposit.