Printable Course Application Form
NDTA, Inc. Bobath Approved Three Week Course
(Use your browser's print command to print this form)
Application by mail: Complete the application form and mail to:

Recovering Function
1582 Pam Lane
San Jose, CA 95120-5707
(408) 268-3691
info@recoveringfunction.com 

Application by fax: Complete the application form and fax to: Recovering Function at (408) 927-6183.
Please fill out this form completely and PRINT clearly or processing of your application may be delayed. Copies of this application form are also accepted. Please use a separate form for each registrant.
Course location ____________________________
Course dates _____________________________________
Participant information
Please specify your name and credential as you would like them to appear on your certificate.
Name: _________________________________________
Credential: ____________(e.g. OTR/L, MPT) 
Nickname for name tag: __________________________
E-mail: _____________________________
Home phone: _________________________
Work phone: _________________________
Work fax: ___________________________
Country: ____________________________
Home address: _______________________________________
City: ______________________ State:______ Zip:___________
Facility name : _________________________________________
Street: __________________________________________
City: _________________________ State:______ Zip:___________
How did you first hear about this course?: __________________________
Since you will be actively interacting with patients during this course, you are either responsible for your own liability insurance or for assuring that your employer's insurance will cover you at this course. Upon acceptance into the course, you will be required to submit either a certificate of insurance or other proof of coverage that will cover you during the time you are participating in the course. This includes both Part I and Part II.
Professional school attended: ____________________________________
Date graduated: ________________________
Highest degree earned: ____________________________
How long have you worked in your present position?: ________________
Do you plan to return to this employer after the course?: _____________
If not, what are your plans?: _____________________________________________
Current employment:
Hours of direct therapy weekly with adults with hemiplegia (in the past year):
2 to 5 ______ 6 to 10 ______ over 10 ______
What type of facility are you working in?:
Acute ______ Rehab ______ Home care ______ SNF ______ Other ______
Are you planning to continue actively treating patients with adult hemiplegia after this course?: ______
Responsibilities: (percent of time weekly - should total 100%)
Supervisory/Administrative:
25% ______ 50% ______ 75% ______ 100% ______
Direct patient treatment:
25% ______ 50% ______ 75% ______ 100% ______
Clinical teaching:
25% ______ 50% ______ 75% ______ 100% ______
Classroom teaching:
25% ______ 50% ______ 75% ______ 100% ______
Clinical research:
25% ______ 50% ______ 75% ______ 100% ______
Experience:
Total years of full-time experience with adults: _____________________
Total years of experience with adult hemiplegia: _____________________
Describe any prior training you have had in this approach:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Is another team member from your facility applying for this course?: __________________
If yes, name(s): ____________________________________________
Are others from your facility NDT trained?: __________________
If yes, please indicate name, discipline, peds/adults, when/where trained for each person:
___________________________________________________________
___________________________________________________________
___________________________________________________________
If you are accepted, will you be able to participate in all the physical requirements of this course? This includes transferring severely involved patients, facilitation of classmates and being facilitated by classmates?: __________________
Possible limitations (describe):
__________________________________________________________
__________________________________________________________
__________________________________________________________
Have you previously applied for a NDTA Inc. Bobath Three Week Course and not been accepted? __________________
If yes, please provide the dates and locations of each course:
__________________________________________________________
__________________________________________________________
__________________________________________________________

Please attach copies of letters stating you were qualified but not accepted into these courses from either the facility or instructor of the course.
Letter of reference:
Please have a professional colleague who is acquainted with your clinical skills complete a letter of reference which addresses these topics:
  • Briefly describe your clinical skills, including your most effective areas of patient treatment
  • Describe your ability to function in a group
  • Describe your ability to function in a learning situation, including your ability to receive constructive criticism

Your colleague should indicate his/her facility name and position.
Personal statement:
Please attach a personal statement of your reason for applying for this course. Include how and where you plan to apply the knowledge gained, and other pertinent information.

Note: NDTA Inc. is the national association that regulates the qualifications of the applicants as well as the credentials for the instructors for these courses.