Volunteer’s Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Professional Status *

Student

College Graduate

Licensed/certified to practice

Profession *

(one choice only)

Occupational therapy

Physical therapy

Speech language theraphy

Professional Teacher”

Others, please specify:

Date available to start work *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Choose the volunteer/professionals organization/s that you are affiliated with. Contact us if you wish your organization to be included in the list. *

Philippine Physical Therapy Association (PPTA)

Philippine Academy of Occupational Therapists (PAOT)

Philippine Association of Speech and Language Pathologists (PASP)

Univeristy of the Philippines - College of Allied Medical Professions Alumni Association (UPCAMPAA)

Project Therapy Education and Assimilation of Children (TEACH)

Rehabilitation and Empowerment of Adults and Children with Handicap Foundation, Inc. (REACH)

Philippine Community-based Disability Inclusive Development (PCBDIDA) Teach

Autism Society Philippines (ASP)

Down Syndrome Association of the Philippines, Inc (DSAPI)

Independent Living Learning Centre, Inc. (ILLC)

Others, please specify:

How did you learn about us? *

Doctor

Colleagues

Website

Facebook

Alumni organization

Professional organization

TV / newspapers

Brochures

Conference

Others, please specify:

Do you have any current pending issues (e.g. suspensions, disciplinary/legal cases, etc.) under PRC, your professional organization, and/or relevant bodies that prohibit you from practicing? *

Yes

No

CERTIFICATION *

I hereby certify that the foregoing information are is true and correct. I understand that any false statement or information in this application may will render my application void. I certify that the information given herein is correct and complete. Deletion and/or falsification of information on this form may nullify my application and/or dismiss me from the volunteer program.

I have read and understood the terms and conditions: https://www.reachcbr.org/terms-and-conditions-volunteers