Name: * Address: * Phone Number: * E-mail: PT program that you are in (school): Does your school have a contract for PT clinical internships with our facility?   Yes       No  Would you like to set one up with our facility?   Yes       No  Year in PT program: What clinical is this for you?   First       Second       Third  Are you interested in setting up a clinical affiliation with us?   Yes       No  What are your interests:   Orthopedics    Sports Medicine    Neurological    Women’s Health Issues    Cancer Fatigue Recovery  You have already set up an affiliation with us and need some information about housing:   Yes       No  For any other questions regarding your affiliation e-mail Jeff Gilliam MHS PT CCCE at Jeffgrehab@ghfc.com * = Input is required