2025 STEP Spasticity Scholarship

1. Scholar information

First Name *This question is required.

Last Name *This question is required.

Degree(s) *This question is required.

Institution *This question is required.

Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

Country *This question is required.

The address listed above is: *This question is required.

Phone Number *This question is required. This question requires a valid number format.

Email Address *This question is required. This question requires a valid email address.

2. What year of training are you currently in?
*This question is required.

Please enter an 'other' value for this selection.

3. Have you completed the following in your training?
*This question is required.

20 toxin injections

10 Ultrasound Scans

4. How familiar are you with Ultrasound and EMG Principles? (On a scale of 1-5, with 1 being not familiar and 5 being very familiar)
*This question is required.

Not Familiar

Very Familiar

Comments

5. How would you rate your knowledge of MSK anatomy and kinesiology? (On a scale of 1-5, with 1 being not familiar and 5 being very familiar)
*This question is required.

Not Familiar

Very Familiar

Comments

6. Describe any experience you may have to date performing focal chemodenervation (botulinum toxin, nerve and motor point blocks) and intrathecal baclofen delivery treatments on patients with spasticity.
*This question is required.

7. Why do you want to participate in this program? Please include any information regarding how you plan to integrate interventional spasticity into your future practice.
*This question is required.

8. Please attest to the following statements by checking each box:
*This question is required.

I understand that I will be required to complete the online program before April 18, 2025 (approximately 9.5 hours of online education).
I understand that I will be required to attend the entire two-day course on April 25-26, 2025, in Rosemont, IL (next to O’Hare International Airport) and will be responsible for my own course travel and hotel expenses.
I understand that I will be required to attend the in-person skills assessment on Wednesday, October 22, 2025, in Salt Lake City, and will be responsible for any travel costs involved.
I understand that space is limited, and if I am unable to attend the course for any reason, I will let AAPM&R know as soon as possible and no later than two weeks prior to the course.

9. Electronic Signature
*This question is required.

Name

Date This question requires a valid date format of MM/DD/YYYY.

calendar

10. Attach CV *This question is required.

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