Membership

KCRA membership application

*This application for membership is for March, 2010 – March 2011.  If you joined KCRA at the conference then your memebership will be due a next conference.  If you are new then send in your registration now and it is good until next year.

Please make checks payable to K.C.R.A and mail to:

Peggy Cox, RN, RRT
Pulmonary Rehab   Frazier Rehab Institute
220 Abraham Flexner Way
Louisville, KY 40202

or

You can pay online using Paypal:

Membership Payment



Your Email Address :




(Please note: after you pay with Paypal, you will be brought back to this page to finish the registration.)

Questions?
Contact Peggy Cox at peggy.cox@jhsmh.org or  (502) 582-7620.

If you prefer to download, print and mail the form, you may obtain it in word format by clicking here.

2010 KCRA Membership Application

By entering your email address you will receive updates throughout the year on various topics. Your information will not be sold or shared with anyone outside of AACVPR affiliate societies.

All fields MUST be filled in…

Date of Birth:

First Name:

Last Name:

Email Address:

Preferred Mailing Address
 Home Work

Street Address:

Street Address Line 2:

Apartment Number:

City:

State:

Zip:

Phone:

Fax:

Degrees:

Certifications/Licenses:

Hospital or Institution you work for:

Current Involvement (check all that apply)
 Inpatient Cardiac Rehab
 Outpatient Cardiac Rehab
 Inpatient Pulmonary Rehab
 Outpatient Pulmonary Rehab
 Student
 Other

Professional Affiliation (check all that apply)
 Educator
 Registered Nurse
 Exercise Physiologist
 Respiratory Therapist
 Certified Exercise Specialist
 Physician
 ACSM Exercise Specialist
 ACSM RCEP
 Other

Membership Type
 AACVPR Member ($20/year KCRA Membership fee. Please send a copy of current AACVPR membership card)
 Non AACVPR Member ($25/year KCRA Membership fee.)
 Student ($10/year KCRA Membership fee. Please send a copy of your current student ID)

If you selected Other for either Current Involvement or Professional Affiliation please explain below: