Is a RehabCare Campus Relations representative coming to your school? If so, print out this form and fill it out completely. Then, on the day of your campus event bring it with you and enter it into the drawing to double your chances at winning the giveaway!
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Student Contact Info (Please Print)
___PT ___PTA ___OT ___OTA ___SLP
Name_________________________________________________________________________
Address_______________________________________________________________________
City____________________________________State_________________Zip______________
Home Phone(____)___________________
Cell Phone(____)_____________________
Email:_______________________________________________________________
States/Regions In Which You Prefer to Work:______________________________
Settings in Which You Prefer to Work:____________________________________
School:___________________________________
Graduation Date (Month/Year):_______/____
Permanent Address:____________________________________________________
Permanent Phone:______________________________________________________
Comments:____________________________________________________________
