Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Pre-requisite completed? *

I have completed the Foundations of Hydrotherapy online course?

Yes

No

I am able to attend IN-PERSON *

Yes

Select which Practicum session you are able to attend *

October 16 and 17 2025

I have read and agree with the Statement of Principles *

Yes

No