Application for States Nebraska to Wisconsin Please fill out this application if your school would like to participate in AAOMPT's Student Local Program. This form is for states between Nebraska and Wistconsin when put in alphabetical order. This will direct your application to the appropriate "Members-at-Large" representative.Name of School *President *Student's namePresident's Email *President's Phone Number *Vice PresidentStudent's nameSecretaryStudent's nameAdditional PositionsPosition and name of StudentDPT Program Director *Mentor's Name *Faculty or FellowMentor's EmailMentor's Phone NumberPreferred method of contact *EmailPhonePhoneSubmit
