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#19-004302-0004
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.
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
3.

Describe your experience performing therapeutic recreation work in the treatment of mentally ill, aged, physically ill or physically disabled patients or developmentally disabled clients. 

Please include name of employer, job title, dates of employment, and hours worked per week. This information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.

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