Membership Registration

First Name

Middle Initial

Last Name

Address


City

State

ZIP

Home Phone

Work Phone

Email

Are you affiliated with a Cardiopulmonary Rehab Program?  yes no

Region:  Coastal Mountain Piedmont

Program / Institution Name:

Membership Classification:  Professional Student

Discipline:

 Physician RN - Associate RN - Diploma RN - BSN Exercise Physiology - Bachelor Exercise Physiology - Masters Exercise Physiology - Doctorate Nutrition Mental Health - Masters Mental Health - Doctorate Vocational Rehab Physical Therapy Occupational Therapy Secretarial Science Other (describe below)

Role(s) - May serve in as many as you are qualified; please indicate all roles.

 Medical Director Program Director Nurse Nutritionist Mental Health Specialist Vocational Rehab Counselor Exercise Physiologist Exercise Leader Physical Therapist Occupational Therapist Respiratory Therapist Office Manager / Secretary Other (describe below)

Other disciplines and/or roles (if indicated above):

Licensure / Certifications (list all):

 AACVPR - Member AACVPR - Fellow ACSM - Member ACSM - Fellow AARC - Member AARC - Fellow APA - Member APA - Fellow

Other Professional memberships

For security purposes, please enter the characters below into the following field.
captcha