Encompass Health

First Name *

Last Name *

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Credentials for Certificate *

M.A., CCC-SLPM.S., CCC-SLPPh.D., CCC-SLPM.C.D., CCC-SLPM.Ed., CCC-SLPM.A., CF-SLPM.S., CF-SLPOther

List here if Other

ASHA Number If you are a CF - enter your NSSLHA Number if known.

Phone *

Email *

Billing Method *

Payment through TransAct SmartSystem (A purchase order needs to be sent to Ampcare with this option)Self Pay via invoice

Hospital Name & Address *Please provide any details related to the facility or branch you work for

Company Contact Person *Director of Therapy Operations

Additional Comments

Any special needs (e.g. Dietary or Seating needs for Live CE Training)

Select Course *

Online CourseLive CourseHybrid

Course Date and Location *