HPC Registration Terms and Conditions for High Performance Coaching. Please read prior to registering. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.You must agree to the Terms and Conditions to applyI agreeNo thanksName *FirstLastWhat name do you go by? *example: John, Dr. Smith, Dr. John Smith, Dr. J, Dr. Johnny BoyAre you a Clinical Specialist? *— Select Choice —No, not a specialistOrthopaedicsSportsNeurologyPediatricsPelvic and Women’s HealthGeriatricsCardiovascular and PulmonaryOncologyClinical ElectrophysiologyWound ManagementAre you a board certified clinical specialist in any of the above areas?Do you have multiple board certified specialities? List them here:If you are a clinical specialist, what year did you first receive certification? (copy)Areas of StrengthOrthopaedicsNeurologySportsVestibularPost SurgicalGeriatricsStrength and Conditioning – CSCSCardiacPediatricsOtherYou may not be board certified, but what are your areas of strength? Check all that apply.If other, please explain:School where you received your DPT: Year Other (copy) DPT Graduation YearWhat year did you graduate from DPT school?Undergrad SchoolWhere did you go to school for your undergraduate degree?Did you do a residency?YesNoInterested and LookingI am currently in a residency programDid you do a fellowship?YesNoInterested and LookingI am currently in a residency programOther degrees?List any other degrees hereWhat is your favorite joint?NeckThoracic spineLow backSI jointShoulderElbowForearm, Wrist, HandHipKneeLower Leg Foot and AnkleNone, I do other thingsWhich joints or areas are you most comfortable discussing and teaching?What are you good with?Ortho injury/surgeryStrokesShoulder painBack painNeck painHip painKnee painFoot and ankle painWrist and hand painReturn to Run/ Running AssessmentBasic Bed Mobility and Transfers EducationStrength and ConditioningSport Specific TrainingLong Distance SportsExtreme SportsDancing / GymnasticsTactical AthletesAmputationsVestibularWater SportsSwimmingOtherIf other, please explain here:What is Your Optimal Client?Elite AthleteRetired AthleteWeekend WarriorOlder AdultYoung AdultTeenager / ChildrenWomen’s HealthMen’s HealthOrtho InjuryOrtho SurgeryNeurological ImpairmentCardiac ImpairmentVestibular ImpairmentDizziness / VertigoChronic PainAmputationsSpinal Cord InjuryBrain InjuryConcussionStrokeSwimmingOtherIf other. please explain here:In What City and State do you Currently Work?Example: Tampa, FLOccupation What is your job title?Current Work SettingMy HomeHospitalOutpatient ClinicPrivate ClinicNursing FacilityGymTravel / In HomeOutdoor / ParksSchool / UniversityOtherIf other, please explain here:Do you own your own business?YesNoRather not sayWhat are you interested in learning?List any hobbies, actives, or interests Submit
