Education at USC Chan
Request Program Information

You can use this form to request information about any of our programs. Please make sure that you complete the required* fields so that we know which program/s interest you and how we can best contact you. Thank you!

Once you've completed the form, you'll be able to download the program brochure, and you'll also be sent an e-mail with useful information and links, including a link to the brochure download page.

Are you currently an occupational therapist?*

Yes No

How did you hear about us?*

(check any that apply)

	Advisor Which advisor?:
	AOTA
	Continuing education Which course?:
	Internet Which source?:
	Library
	OTAC
	OTCAS
	OT recruitment mailing
	OT/OS class
	Recruitment event Which event?:
	Speaker in class
	Summer Occupational Therapy Immersion (SOTI) program
	USC Catalog
	USC Graduate Book
	US News & World Report
	WICHE
	Word of mouth Which source?:
	Other Which source?:

Your name

First / given name*
Middle name
Last / family name*

Your location

Zip / postal code*
Country* (change if not United States)

Your contact details

Email address*
Primary phone #
Alternate phone #
Fax #

Can we keep your details?

We would like to keep a copy of your contact details and occasionally — maybe a couple of times a year — contact you about our programs. We will not share your contact details with anyone else and you can ask us to update/delete them at any time. (You can read our general Privacy Policy here.)

Please confirm whether or not you will permit us to store your contact details for this purpose:

Yes No