AACVPR: Membership Application Form

About AACVPR

Membership

Member Benefits

Membership Application

Code of Conduct

Mentorship Information

Annual Meeting

Policy & Reimbursement

Certification

Education & Employment

Resources & Publications

Cardiac Rehabilitation Basics

Pulmonary Rehabilitation
Basics

Members Only

Membership Application Form

Fields with an * are required!

Contact Information

Prefix

First Name

Middle Initial

Last Name

Degree

Enter all degrees, separating each with a comma.

Job Title

Place of Employment

Email Address

Fax

Gender

Male

Female

With which affiliate are you associated?

Address

This address is

Street Address

City

State/Province

Zip/Postal Code

Country

Please select your country if you are outside of the United States

Telephone

Additional Information

Are you a member of your state/regional society?

Yes

In what area(s) do you spend the majority of your practice?

What is the emphasis of your clinical practice?

Who is your employer?

If other

Is your facility free-standing?

Yes

How many new outpatients would you estimate are seen in your program annually?

How many new inpatients would you estimate are seen in your program annually?

Which of the following best describes the emphasis of your work environment?

How many years have you been involved in rehabilitation?

How many health care professionals work in your program (both full and part time)?

Where did you hear about AACVPR?

What made you decide to join AACVPR?

Membership

Membership Category

Questions for Members

Which of these categories best represents you?

If you are certified by a professional association, please tell us the:

Association Name

Certification Name

Questions for Students

Student ID

Are you currently enrolled as a student?

Yes

Major

Year Degree Expected

Advisor Name

Advisor Telephone

Questions for Associates

Primary Occupation

Major Area of Interest

* Membership Agreement

I certify that the above information is correct and I agree to abide by the Code of Ethics and Professional Conduct of the American Association of Cardiovascular and Pulmonary Rehabilitation as outlined on this application.

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