IAR

Institute for athlete regeneration

Applicant Information
Last Name: / First: / Middle Initial:
Credentials (PT, DPT, OCS, SCS, etc.): / DOB:
Specify the Manual Therapy program you are applying for:
Fellowship Certification
Primary Referral Source:
IAR Website AAOMPT / APTA Directory IAR Faculty / Fellow - Name:
Specify the primary program location you are applying for:
Houston, TX Austin / San Antonio, TX Charlotte, NC
Primary Email Address: / Primary Phone Number:
Home Address:
City: / State: / Zip:
Emergency Contact: / Phone Number: / Relationship:
PT Licensure: YES; See below NO; Anticipated Date of Acquisition:
State: / License #: / Expiration:
*Do you carry Personal Professional Liability Coverage? YES NO / Provider:
*NOTE: IAR requires ALL participants to carry their own coverage throughout the length of the program.
Memberships: APTA AAOMPT Other(s):
EMPLOYMENT INFORMATION
Name of Company:
Work Email: / Phone Number:
Address:
City: / State: / Zip:
Employment Position:
Years of active clinical practice:
Primary patient population treated:
academic background
Entry Level Degree Earned:
Baccalaureate Master’s (MPT, MS, etc.) DPT Residency Trained
Name of Institution: / Year of Graduation:
Statement of interest
Briefly, tell us why you would like to participate in our program; interesting facts about you are appreciated.
Program participant agreeement
I certify the above information is true and factual to the best of my knowledge. I understand I will not be covered by IAR liability insurance and will need to acquire my own Professional Liability coverage at no expense to IAR prior to starting the program. I understand that I will participate in activities that require me to perform manual therapy techniques on other participants and the same techniques to be performed on myself. I am aware these techniques pose a risk of bodily injury to others and myself. Due to this risk, I understand that I will be asked to sign a contract to hold harmless IAR, IAR faculty, and Select Physical Therapy for any possible injuries that may occur to myself during my participation in the program; and waive my right to seek legal action against IAR and/or Select Physical Therapy for injuries that may occur. IAR reserves the right to formally interview all applicants to ensure they fit the IAR philosophy and understand the commitment necessary to successfully complete the program. By checking the box below, you acknowledge that you have read this statement, understand its implications, and agree to the aforementioned conditions.
I agree to the above statement: Yes No
Signature: / Date:
Please Ensure Application is Complete. Email completed application to . You will receive an acceptance status within 10 days.
For Office Use Only:

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