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#18-004283-0002
Supplemental Questionnaire

Last Name
First Name

 

***Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.***


1.

Do you possess a Bachelor's or Master's degree in Therapeutic Recreation or Recreation with a major in Therapeutic Recreation from an accredited college or university?

Yes No
2.

Describe your experience as a professional therapeutic recreator, under the supervision of a licensed Occupational Therapist, licensed Physical Therapist or certified Activity Therapist, which included the responsibility for clients’ assessments and the planning, implementation and evaluation of clients’ recreation therapy treatment in a mental health or developmental disability setting.

Please note that experience in assisting with these responsibilities will not be accepted as qualifying experience.  If no experience, please type N/A.

3.
Do you possess a current certification as a Therapeutic Recreator from the National Council for Therapeutic Recreation Certification? (If yes, please attach a copy of your certification to your application.)
Yes No

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