On Demand Public Webinar Certificate Request

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* 1. What is your first and last name, as you would like it to appear on your certificate?

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* 2. Please provide the e-mail address where you would like your certificate to be e-mailed.

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* 3. What is the title of the LSVT Global community On Demand webinar that you viewed?

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* 4. What is the date that you viewed the LSVT Global community On Demand webinar?

Date / Time

Date

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* 5. Do you attest to viewing the webinar for the full duration?

Yes

No

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* 6. Please list 3 items that you learned from the webinar.

Learning Item #1

Learning Item #2

Learning Item #3

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* 7. Please provide the name of your discipline, whether a student or professional (e.g. speech-language pathology, physical therapy, occupational therapy), so that your certificate can be formatted appropriately.

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* 8. Please rate the audio and visual quality of the webinar.

	Excellent	Good	Acceptable	Poor	Horrible
Audio Quality	Audio Quality Excellent	Audio Quality Good	Audio Quality Acceptable	Audio Quality Poor	Audio Quality Horrible
Visual Quality	Visual Quality Excellent	Visual Quality Good	Visual Quality Acceptable	Visual Quality Poor	Visual Quality Horrible

Comments on audio and visual quality:

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* 9. If you have any suggestions for future webinar topics we would love your input! Please provide any suggestions below.

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* 10. If you have any additional comments, please include them below.

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* 11. If you have a question for an LSVT LOUD or LSVT BIG Faculty Instructor, please write it below and include your contact info (name, phone number and/or e-mail address) so we may reach out to you.