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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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
