UK Ampcare ESP Hybrid Registration

Registrant's Name

First

Last

Number Credentials comments

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

SLT Email

List Here if you selected Other

Affiliation

Trust, Company or Facility Name

Health and Care Professions Council (HCPC) Number

Relevant license to practice number for your credentials

Finance Email Address

On-Demand Training Option

Hybrid: On-Demand + Zoom Webinar

Hybrid: completion of 4-hours of pre-work required before the 1st Zoom meeting date.

Will you be purchasing the ESP Kit

Will you need ASHA CE Hours

You are an International Member of the American-Speech-Language-Hearing Association and will submit these CE Hours for renewal

List ASHA Number here if applicable

Any additional comments