1. Name:        Discipline:  OT  PT

2. College/University: 

3. Permanent Address (where pre-clinical information should be sent):
                 

4. Present Telephone Number:    Best time to reach you: 

5.Coursework completed relating to Mental Retardation, Developmental Disabilities and/or Exceptional individuals: 
     

6. Work or other experience you have had with persons with mental retardation/developmental disabilities:
  

7. Where did you have your Level I Clinical experience's)?  Please indicate the number of weeks, and describe   the type of facility as well as the diagnoses and therapeutic procedures that you came in contact with:   
  

8. Briefly describe yourself.  What would you like your clinical coordinator and/or instructor to know about you as a person?
    

9. What are your objectives for a clinical education experience at CVTC?
  

10. What clinical skills would you like to enhance during this affiliation?
   

11. How would clients of CVTC benefit from your placement?
   

12. How much reading and preparation for evaluation, treatments and progress do you expect to do during the clinical? 
      None  As required during work hours  At least 1-2 hours every evening

13. How do you learn best?
   

14. Describe any conditions (medical or otherwise) that may affect your ability to perform during the clinic that we need to be aware of.  Are accommodations required?
     

15. As part of the application process, please have two letters of personal reference and an academic transcript set to: 
       Betty C. Little, College/University Liaison, Central Virginia Training Center, P.O. Box 1098, Lynchburg, VA 24505

16.  Questions?  Call Betty C. Little at 434-947-6354.

17. Email address: