Full Name (First & Last)

Preferred Name (if different than above)

Email address

Phone number

Address (including number, street, city, state, country, postal code)???

Date of Birth

Occupation
OT/OTAOT StudentPT/PTAPT StudentSLP/SLPASLP StudentOther

Professional Degree (e.g. OTD, DPT, etc.)

If you are a student, please include your university and expected graduation date.

Practice setting (i.e. university, outpatient, school-based, hospital, etc.)- Clinicians only

City, State, Country where you work or study

Name of workplace/company or institution

Specialty & Sub-specialty

Certifications

Number of years in practice
N/A I'm a student0-2 years2-5 years5-10 years10 + years

What language(s) are you fluent in?
EnglishEastern ArmenianWestern ArmenianOther

In what capacity are you interested in volunteering?
Travel, Volunteer In-PersonTravel, Provide Clinical InstructionProvider-to-Provider Consultation (Remote)Live or Recorded Webinars/Presentations (Remote)Contribute to Resource Library (Remote)Advocacy (Remote)

Have you volunteered in Armenia or Artsakh previously?
YesNot yet!

Members are required to join a committee in order to promote active engagement and collaboration. Please select your first choice (We will follow up with you and discuss in detail before you commit).

Fundraising: organize fundraising initiatives, create merchandise to be sold on our websiteProfessional Development & Education: organize collaborative learning opportunities for US & Armenia/Artsakh membersSocial & Networking: plan social events, promote networking opportunities, and expand our organization's connectionsAdvocacy & Marketing: create social media posts, spread awareness and education about issues related to rehabilitation, disability, and organization initiatives
Please select your second choice.
Fundraising: organize fundraising initiatives, create merchandise to be sold on our websiteProfessional Development & Education: organize collaborative learning opportunities for US & Armenia/Artsakh membersSocial & Networking: plan social events, promote networking opportunities, and expand our organization's connectionsAdvocacy & Marketing: create social media posts, spread awareness and education about issues related to rehabilitation, disability, and organization initiatives

If there is additional information you would like to share, or if you have questions please let us know!

After clicking "send" , you will automatically be taken to the dues payment page. **Membership is not complete until dues are paid ($25 USD/year).**