THOMAS FISHER, PHD, OTR, CCM, FAOTA, CHAIR

LET US HEAR FROM YOU

Name ___________________________________________________ Degree received from IU OT Program First Middle Last

_____ AS _________ Year _____ BS _________ Year _____ MS _________ Year ____ OTD _________ Year

Last name while in OT Program (if different from above)___________________________________________

Home Address (check if new____) ____________________________________________________________

City_____________________________________________________________State_________Zip_________

Phone __(______)____________________E-Mail_________________________________________________

Present Position:

Title______________________________________________________________________________________

Facility___________________________________________________________________________________

Facility Address____________________________________________________________________________

News to share______________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

May we publish the above information in the Newsletter?

Yes ______

No ______

(Phone numbers will not be published.)

Send to:

IU OT Alumni Newsletter

Phone: 317-274-8006 FAX 317-274-2150

Department of Occupational Therapy

311 Coleman Hall

E-mail: hummelp@iu.edu

1140 West Michigan Street Indianapolis, IN 46202-5119

13

Made with FlippingBook flipbook maker