SOS Approach to Feeding Certification Application

Contact Information

Name:*
Title:*
Organization:*
Address:*
Phone:*
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Mobile Phone:
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E-mail:*
Verify E-mail:*
Website Address:

Professional Experience & Focus

Profession:*
If you selected other, please specify:
Primary Work Setting:*
What is the primary population of your feeding therapy services?*
If you selected Other, please specify:
How many years of pediatric work experience do you have?*
How many years of feeding therapy experience do you have?*
What percentage of your caseload is Feeding Clients?*
How many years have you been implementing the SOS philosophies into your practice?*
At what level do you implement the SOS philosophy?*

SOS Basic Conference (pre requisite to certification program)

City of Conference:*
Advanced Courses (if applicable):
Basic Course - Upload your Basic conference certificate. (Please contact the conference host if you need a replacement copy).*
Advanced Workshop - Upload your Advanced Workshop certificate. (Please contact the conference host if you need a replacement copy).(1)*
Advanced Workshop - Upload your Advanced Workshop certificate. (Please contact the conference host if you need a replacement copy).(1)(1)*

Certification Program

How did you hear about the Certification Program?*
If you selected the option - Other, please specify:
What are your goals for the Certification Program (Please list up to three main objectives):*

Document Uploads

Upload CV or Resume (please include a detailed list of continuing education programs that you have attended, noting dates and instructor's names):*
Upload a personal photo:*
By checking the box, I have read and understand the cancellation policy.*
By checking the box, I have read and understand the course requirements and expectations of participants.*