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Performing Arts Special Interest Group Survey

Name:
Prof. degrees/certifications:

Company name:
Address:
Phone:
Fax:
E-mail:

APTA member number:
Orthopedic Section Member: yes no
Years of experience treating performing artists:

What percent of your patient population are performing arts patients?

Dancers Gymnasts Skaters
Musicians Vocalists Circus Performers

Please list if you are affiliated with any performing arts schools, companies, or groups below:
Do you accept Student Affiliations? Yes No
If yes, would you be willing to be a mentor? Yes No

Are you interested in serving as a mentor to other physical therapists or physical therapy students interested in the treatment of performing artists?
Yes No

Are you interested in serving on any of the PASIG Committees?

Practice Student Scholarship Education
Membership / Website Nominating Research

Can we list your name and contact information on the PASIG website, www.orthopt.org for a membership contact:
Yes No

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