The Upledger Institute
SEMINAR TYPE
CITY, COUNTRY, DATE
Sign-In Sheet
Name______
Address ______
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Work Phone ______Home Phone ______
Cell Phone ______E-mail ______
Profession ______License Number and Expiration Date ______
Would you like to receive e-mail notice of other seminars? Yes ____ No _____
Include on IAHP.com? Yes ____ No _____
Signature ______
Name ______
Address ______
______
Work Phone ______Home Phone ______
Cell Phone ______E-mail ______
Profession ______License Number and Expiration Date ______
Would you like to receive e-mail notice of other seminars? Yes ____ No _____
Include on IAHP.com? Yes ____ No _____
Signature ______
Name ______
Address ______
______
Work Phone ______Home or Cell Phone ______
E-mail ______
Profession ______License Number and Expiration Date ______
Would you like to receive e-mail notice of other seminars? Yes ____ No _____
Include on IAHP.com? Yes ____ No _____
Signature ______
Name ______
Address ______
______
Work Phone ______Home Phone ______
Cell Phone ______E-mail ______
Profession ______License Number and Expiration Date ______
Would you like to receive e-mail notice of other seminars? Yes ____ No _____
Include on IAHP.com? Yes ____ No _____
Signature ______
Name ______
Address ______
______
Work Phone ______Home Phone ______
Cell Phone ______E-mail ______
Profession ______License Number and Expiration Date ______
Would you like to receive e-mail notice of other seminars? Yes ____ No _____
Include on IAHP.com? Yes ____ No _____
Signature ______
The Upledger Institute
SEMINAR TYPE
CITY, COUNTRY, DATE
Teaching Assistant Workshop Evaluation
Your comments and suggestions are of great value. Please note your overall rating and comments.
Meeting Site:
Excellent Very GoodGood Fair Poor
Location______
Hotel Staff______
Sleeping Room______
Meeting Room______
Room Temperature______
Restaurant-Food______
Restaurant-Service______
Comments: ______
Teacher
Excellent Very Good Good Fair Poor
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Apprentice
Excellent Very Good Good Fair Poor
Lectures______
Demonstrations______
Teaching Assistants (Self Evaluation): Please rate on a scale of 1 (needs improvement) to 5 (excellent)
Overall Professional Prompt Attentive Attire Course Knowledge
______
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______
(Fill in your name)
Were there any factors that caused you to be late for any class or TA meetings? If so, please comment.
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What would have assisted in your process? (For example, more orientation from Teacher, attending another course, etc.)
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The Upledger Institute
SEMINAR TYPE
CITY, COUNTRY, DATE
Teacher Workshop Evaluation
Your comments and suggestions are of great value. Please note your overall rating and comments.
Meeting Site:
Excellent Very Good Good Fair Poor
Location______
Hotel Staff______
Sleeping Room______
Meeting Room______
Room Temperature______
Restaurant-Food______
Restaurant-Service______
Comments: ______
______
Teacher (Self Evaluation): Please rate on a scale of 1 (needs improvement) to 5 (excellent)
Overall Professional Prompt Attentive Attire Course Knowledge
______
(Fill in your name)
Teaching Assistants: Please rate on a scale of 1 (needs improvement) to 5 (excellent)
Overall Professional Prompt Attentive Attire Course Knowledge
______
(Fill in TA name)
Overall Professional Prompt Attentive Attire Course Knowledge
______
(Fill in TA name)
Overall Professional Prompt Attentive Attire Course Knowledge
______
(Fill in TA name)
What would have assisted you with the teaching of the course?
______
______
The Upledger Institute
SEMINAR TYPE
CITY, COUNTRY, DATE
Teacher Workshop Evaluation
Please list any students that you feel should repeat this course before continuing in the curriculum and give brief explanation. Also, indicate whether this person(s) should be able to repeat at no charge (because his/her intention and efforts were in the right place).
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The Upledger Institute
SEMINAR TYPE
CITY, COUNTRY, DATE
Teacher Recommendation
Teacher:
Please note below those people that you recommend becoming a Teaching Assistant, Presenter or Study Group Leader.
Name:______
Position (TA, P, SGL): ______Class Level: ______
Any qualifications that need to be met prior to becoming a Teaching Assistant/Presenter/SGL:
______
______
Name:______
Position (TA, P, SGL): ______Class Level: ______
Any qualifications that need to be met prior to becoming a Teaching Assistant/Presenter/SGL:
______
______
Name:______
Position (TA, P, SGL): ______Class Level: ______
Any qualifications that need to be met prior to becoming a Teaching Assistant/Presenter/SGL:
______
______
Name:______
Position (TA, P, SGL): ______Class Level: ______
Any qualifications that need to be met prior to becoming a Teaching Assistant/Presenter/SGL:
______
______
The Upledger Institute
SEMINAR TYPE
CITY, COUNTRY, DATE
Workshop Evaluation
Your comments and suggestions are important to us. Many of us here – from Teachers to administrative staff – review these evaluations to see how we can make each class experience the best possible. Feel free to make specific suggestions for improvement. Your feedback matters!
Excellent Very Good Good Fair Poor
Course Content______
Comments: ______
Teacher
______
Comments: ______
Apprentice______
Lectures ______
Demonstrations______
Comments: ______
Teaching Assistants
______
______
______
What techniques and information did you find most valuable?
______
Were there any areas you would have liked covered in more detail?
______
Did the scheduled breaks meet your needs?
______
Did you like the meeting site? Other ideas?
______
How did you learn about our workshops?
______
Please list the publications specific to your industry that you read most often.
______
How would you compare your workshop experience with others you have taken?
______
Do you plan to continue taking classes in this curriculum? Yes ___ No ___
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Please list any colleagues, schools or training centers that may be interested in our programs.
______
Are there any other comments or suggestions that you would like to make about the workshop?
______
Your Name (optional) ______
Profession ______Number of years in practice ______
Visceral Manipulation: Abdomen 1
SEMINAR TYPE
CITY, COUNTRY, DATE
Workshop Evaluation – Compilation Sheet – Email to UI after seminar
Please count the responses on the Evaluation Forms and list here.
For the questions, please summarize the responses. Number of Students ______
Excellent Very Good Good Fair Poor
Course Content______
Comments: ______
Teacher
______
Comments: ______
Apprentice______
Lectures ______
Demonstrations______
Teaching Assistants
______
______
______
______
What techniques and information did you find most valuable?
______
Were there any areas you would have liked covered in more detail?
______
Did the scheduled breaks meet your needs?
______
Did you like the meeting site? Other ideas?
______
How did you learn about our workshops?
______
Please list the publications specific to your industry that you read most often.
______
How would you compare your workshop experience with others you have taken?
______
Do you plan to continue taking classes in this curriculum? Yes ___ No ___
______
Are there any other comments or suggestions that you would like to make about the workshop?
______
SEMINAR TYPE
CITY, COUNTRY, DATE
TEACHER’S NAME
EVALUATION OF PARTICIPANTS AND STAFF
This form is intended as a support mechanism for participants. The Information helps us to identify those who need additional assistance during class, as well as those who may make excellent teaching assistants (assuming all other qualifications have been met). It is not necessary to comment on students with whom you have no contact or those who are progressing as expected for this class level. If, at the end of the class, you feel that a student should repeat this course before proceeding to the next level in the curriculum, please bring it to the attention of the Teacher.
PREPARED BY: ______(Please fill in your name)
Indicate any palpation skills or concept application comments. Please use reverse for additional comments as necessary.
√ TA Rec. / √ Study Group Leader Rec. / √Presenter Rec. / Comments / Name
Student Name
Student Name
Student Name
Student Name
Student Name
Student Name
Student Name
Student Name
Student Name
Student Name
Student Name
Student Name
Student Name
Student Name
Student Name
Student Name
The Upledger Institute
8380 Woodsmuir Drive
West Palm Beach, FL33412
Policies, Procedures and Code of Ethics Relating to
Visceral Manipulation and Nervous System Curriculums
We are pleased to provide you with this training opportunity. We hope that you benefit greatly from this experience and that you apply the concepts and techniques with success in the future.
It is essential that the purity of this work and the high-quality teaching standards that have been established for this curriculum are maintained. As such, if you wish to present or teach any portion of the copyrighted material from this workshop, you must first undergo the required training and/or obtain written permission from The Upledger Institute (UI).
Upon course completion you are invited to take advantage of the UI’s many ongoing programs and resources. Information is currently available to help you successfully:
- Submit a press release on your continuing education experience and clinical practice
- Get articles published on techniques, applications, client cases and more
- Form a study group
- Train to become a teaching assistant, presenter and Teacher
- Network as a technique demonstrator at trade shows
Please let us know your area(s) of interest. We will gladly assist you in determining the most productive use of your assets, as well as support you in organizing presentations, etc. Working together will ensure that the information presented is current, correct and professionally supported with collateral materials.
As a practitioner using therapies taught through UI you are expected to adhere to the highest professional standards. Among these are the commitment to provide quality therapy to all persons without discrimination, to seek educational opportunities to enhance therapeutic skills, to respect each client’s right to privacy, and to accept the responsibility to do no harm to the physical, mental and emotional well-being of self, clients and associates.
Insurance reimbursement policies vary for manual therapies. If insurance reimbursement is an integral part of your practice, we encourage you to verify insurance acceptance for your profession in your area.
Finally, attendance at this training is not intended to be used as a hands-on license. You must work within your professional scope of practice and abide by the rules and/or laws that govern healthcare practices in your applicable region (i.e., city, state or province).
If you have any questions about these or other issues, please contact UI at
Suggested Name Tag Format
The Upledger Institute
Julie
Julie Smith
Adelaide