Misericordia University

Misericordia University
OCCUPATIONAL THERAPY DEPARTMENT

Please check the boxes you are interested in and submit this form.

	If you would like to receive an e-mail from a current Occupational Therapy student please include your e-mail .
	If you would like to attend a sample Occupational Therapy class at Misericordia University, please check this box.
	If you are a current Jr. in High School and would be interested in receiving information about our Summer Camp Program, check this box and enter email address below.
	If you would like to Job Shadow an alumnae of our program, check this box.
	If you would like to visit our campus and meet with a Misericordia University Occupational Therapy Faculty member, check this box.
	If you would like to visit our campus, check this box.
	Please include your name, address and phone: Name: Address: City: State: Zip: Phone: E-mail:

Thank you for your response. If you have any questions please call Dr. Joseph Cipriani at (570) 674-6412
or email at jciprian@misericordia.edu.