Registration/Application Request

ALL the information below is required to submit your registration.

No classes scheduled

Please provide ALL of the information we ask for - each piece has a purpose. We need your first, MI (if you have one) & last name in the name field please. A first name only is not acceptable.

*Full Name (Last, First):                     *Job Series/AOC/AFSC:                                   *Grade/Rank:

*Job Title:           Component: Army, Navy, Civilian DAC, (Non-Gvt)/ Contractor, etc:

Gender:    Male    Female

A DVD will be sent to your office after completion of the course. Please provide a complete office mailing address, including the building number or street address. Your home address is not acceptable.

Complete Official Office Mailing Address, Including BDE/BN/CO:, and Building Number

Commercial Phone Number - REQUIRED:

Work E-Mail Address:                            *AKO E-Mail Address:

1. What is your PPPT program position title? Choose one of the following: Medical Expert, Education Coordinator, Trimester Instructor Trainer, Program OIC or NCOIC

2. What medical and fitness background/experience do you have? (for example, MFT, medic, nurse, aerobics instructor, degree in fitness-related subject, current PPT EL):

3. Who is responsible for PPPT Program Execution at your location?

Garrison    Installation Commander    Division Surgeon    Brigade    Battalion    MEDDAC

4. Are you on a temporary or permanent profile?    Yes    No

5. If you are on a temporary or permanent profile, what are you restricted from doing?

6. Have you secured funds for this TDY?    Yes    No

SUPERVISOR information is Required.

Supervisor's Name:                    Supervisor's Title:                    Supervisor's Phone Number:               Supervisor's E-Mail Address:

For questions, contact the PPPT Program SME at DHPWWebContacts2@amedd.army.mil or by phone at 410-436-4656, DSN: 584-4656