CRC Physical Therapy Volunteer Application

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The Community Rehabilitation Clinic (CRC Physical Therapy) encourages volunteer participation by those who support its mission. Please complete this application and give to the Office Manager at the clinic at 587 South State Street in Provo, UT 84606. We will set up a time for an introduction to the clinic and staff, training in CRC procedures, and schedule according to your availability. The information on this form will be kept confidential and will assist us in determining the most appropriate volunteer opportunity for you. Thank you for your interest and willingness to help out in the Community Rehabilitation Clinic!

Name: Fielding Dalmer *

Date: 11/01/2023 *

YYYY

Phone #: 971-303-6871 *

Address: 521 S 500 E Apt E308 *

City: American Fork *

Zip Code: 84003 *

Email: fieldingdalmer@hotmail.com *

Employer: Shriners Children’s

Work position: Rehab Aide

Student? No *

Option 1

Yes

School:

Major:

How far are you in school?

Reason for volunteering: *

How did you hear about the clinic? *

Speak another language? *

Yes

Which language(s)?

Any clinical experience? *

Yes

If you do have clinical experience, please explain: (how long, what you did, where you got your experience, etc.)

Any certifications? *

Yes

Which certifications?

Which type of physical therapy are you interested in? (you can select more than one if you would like) *

Orthopedic

Multiple Sclerosis Wellness Program

Other Neurological

EMG (Nerve Conduction Study)

Pelvic Floor

Vestibular

Post COVID-19 Therapy

Required

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