Test Reg 2018 Annual Meeting Registration Attendee First Name * Attendee Last Name * Preferred FULL Name for Badge * Please list your preferred FIRST and LAST names for your badge Credentials ATC MA MS EdD PhD MD PT DPT RN CSCS OtherOther Attendee Address * Attendee Address Attendee Address Attendee Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Employer/School Attendee E-mail Address * This is the e-mail address that will receive informational e-mails regarding the Annual Meeting. If you use a secondary school, college/university,or hospital email address, we encourage you to instead use a personal email address (e.g., Yahoo, Gmail) on your registration. Email addresses with certain extensions are more likely to block incoming emails. The post-event assessment/survey and your Statement of Credit are both sent via email. E-mail a Copy If you would like the registration confirmation sent to another email please add it here. (ie. Copy to Program Director or Accounting) Phone Number * Contact number in case issues arise regarding registration Emergency Contact First * Emergency Contact Last * Emergency Contact Phone * Do you require learning accomodations? * Yes No Accomodations requested: * Are you a Certified Athletic Trainer within the first 12 years of certification? * Yes No SURVEY: Do you have an NPI Number? * Yes No No? Join the rest of us that can say "Yes" and take 5 minutes to sign-up or one! Follow the link below to sign-up and get your very own! Then don't forget to mark your answer "Yes" NPI Sign-Up (Opens new Tab) SURVEY: Would you like the conference vendors to be able to contact you at the information provided above? * Yes No Member Status Are you an NATA Member? * Yes No NATA Member Number * Are you an MAATA Member? * Yes No NATA/MAATA Member Number * Are you a certified Athletic Trainer with the BOC? Yes No BOC Number * Are you a current undergrad/graduate student? * Yes No Undergraduate or Graduate? * Undergraduate Graduate Is your member status 'Retired'? * Yes No Are you speaking at the conference? * Yes No Conference Option
