Membership Renewal Form _PDF_ -

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Membership Renewal Form _PDF_ - Powered By Docstoc
					American College of Sports Medicine                                                                               FOR BEST SERVICE complete this form
                                                                                                                  online at www.acsm.org/join or
Membership Application                                                                                            1. Mail it with payment to ACSM,
                                                                                                                  Department 6022, Carol Stream, IL
                                                                                                                  60122-6022
                                                                                                                  2. Fax it to (317) 634-7817
PLEASE PRINT INFORMATION LEGIBLY.

Have you previously been a member of ACSM? [ ] No [ ] Yes; previous ID #______________
Select One: [ ] Dr           [ ] Mr     [ ] Mrs       [ ] Miss      [ ] Ms
First Name: ______________________________ Middle Name: __________________________________
Last Name: ______________________________ Nickname:_____________________________________
Gender: [ ] Male [ ] Female                              Ethnic Background (optional): ______________________________
Address 1: ______________________________________________________________________________
Address 2: ______________________________________________________________________________
City: _________________________________________                                     State: _____________                Zip: ________________
Country: ______________________________________                                          Is this a business address? [ ] Yes [ ] No
Work Phone: ______________________________ Home Phone: _________________________________
Fax:_________________________________ E-mail: ___________________________________________
Birth Date: ____________________________ Highest Degree Earned: _____________________________
Area of Interest: ___________________________                               Occupation Code: _____________________________
                       (select code from back of form)                                                  (select code from back of form)

(If occupation is not listed on back of form, Please provide):________________________________________
ACSM Sponsor/Recruiter (if applicable): _______________________________ Sponsor’s ID#: ___________

MEMBERSHIP CATEGORIES (see membership category definitions on back of form)
Membership will begin when payment is processed, and run 12 months from that time.
OPTION 1
   [ ] Professional and Fellow ($220). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________
   [ ] Professional-In-Training ($155). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________
   [ ] Graduate Student ($80). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________
   [ ] Undergraduate Student ($80) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________
                                                                                  ®
   [ ] Add subscription to ACSM’s Health & Fitness Journal ($30) w/above membership $ _________
   [ ] Add expedited international delivery of Member Benefit Journal ($60) . . . . . . . . . . $ _________
OPTION 2
   [ ] ACSM’s Alliance of Health and Fitness Professional Level ($90) . . . . . . . . . . . . . . . $ _________
   [ ] Student Alliance ($50) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________
REGIONAL CHAPTER MEMBERSHIP (available with paid Option 1 or 2)
(select chapter code from back): _______
   [ ] Student ($15) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________
   [ ] Non-Student ($35) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________
DONATION TO ACSM FOUNDATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________
                                                                                                                     TOTAL $ _________
PAYMENT INSTRUCTIONS
Method of Payment: (All payments must be made in U.S. dollars.)
  [ ] Check payable to ACSM ($25 fee for returned checks)                                                                  ACSM Federal ID# 23-6390952
           ®                    ®
  [ ] Visa   [ ] MasterCard

Card Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __                                    Expiration Date: __________
Signature: __________________________________________________
I affirm the statements made by me on this application are correct and that I meet the requirements for the membership category I have requested. If choosing Professional,
Professional-in-Training, Graduate Student, or Undergraduate Student category, I understand that $28 of my membership dues is allocated to a one year subscription to
Medicine & Science in Sports & Exercise®. ACSM membership is based on anniversary year. By signing here I agree to review the ACSM Code of Ethics located at
www.acsm.org/ethics. ACSM membership is individually based, thus you retain your membership even if you change employers. Accepted applications are non-refundable.
                                              Signature: ____________________________________________ Date: ________________
Join a Chapter (OPTIONAL)                                                                 Areas of Interest
$35 Professional, Fellow, Professional-in-Training                                        When completing your application for membership, please select your area of
$15 Undergraduate/Graduate Student                                                        interest from three categories below:
                                                                                          ● Basic and Applied Science: If your career involves fundamental and/or
Add a Regional Chapter to your membership. It’s the best way to connect to                    practical applications in teaching, research, or clinical settings, which
ACSM locally. Regional Chapters offer unique opportunities to interact more                   encompass the disciplines of exercise physiology, biochemistry, motor control,
directly and frequently with fellow sports medicine and exercise science                      psychology, athletic medicine, sociology of sports, rehabilitation, or growth
professionals and students. While specific benefits vary by chapter, common                   and development, then select Basic and Applied Science as your area of
benefits include: Networking opportunities, Discounts on yearly chapter                       interest on your membership application.
educational programs, Chapter Member newsletters, Student awards and                      ● Education and Allied Health: If your primary career is in the teaching of others,
scholarships, Leadership and professional growth opportunities, and Chapter                   whether in a formal educational setting or in a more informal setting, such as
Member forums.                                                                                individual or group health-related functions under physician guidance or
To join one or more Regional Chapters, indicate the Chapter Code on the front of              prescription then select Education and Allied Health as your area of interest
this form. Include the additional dues in your total payment. All Regional Chapter            on your membership application.
memberships are on an anniversary year basis and are not transferable.                    ● Medicine: If you are licensed to practice medicine and/or surgery or possess
                                                                                              an equivalent licensure and your main occupation is the actual practice of the
Chapter         ACSM Regional            Regions Included:                                    licensed profession then select Medicine as your area of interest on your
 Code             Chapters                                                                    membership application.
   1            Alaska                   AK                                               If you are joining as an Alliance member you do not need to select an area of
   2            Central States           AR, KS, MO, OK                                   interest or an occupation code when filling out your membership application.
   3            Greater New York         NYC, Nassau, Rockland, Suffolk &
                                         Westchester Counties, Bergen, Essex,             Occupation Codes
                                         Hudson                                           Choose the career from the following occupation
    4           Mid-Atlantic             DE, MD, PA, WV, Washington D.C.                  101 Anatomist                             211 Ophthalmologist
                                         and those areas of NY and NJ not                 102 Applied Physiologist                  212 Orthopedic Surg.
                                         covered by GNY Chapter                           103 Biochemist                            213 Pediatrics
   5            Midwest                  IA, IL, IN, MI, OH, WI                           104 Biomechanist                          214 Physiatrist
   6            New England              CT, MA, ME, NH, RI, VT                           105 Coach                                 215 Podiatrist
   7            Northland                MN, ND, NE, SD                                   106 Ergonomist                            216 Psychiatrist
   8            Northwest                ID, MT, OR, WA                                   107 Exercise Biochemist                   217 Radiologist
   9            Rocky Mountain           CO, WY                                           108 Exercise Physiologist                 218 Other Medicine
  10            Southeast                AL, FL, GA, KY, LA, MS, NC, SC, TN, VA           115 Kinesiologist                         301 Athletic Trainer
  11            Southwest                AZ, CA, HI, NM, NV, UT                           116 Sports Psychologist/Sociologist       302 Kinesiotherapist
  12            Texas                    TX                                               117 Veterinarian                          303 Health Educator
                                                                                          118 Other Basic and Applied Science       304 LPN
Secondary Address (if needed)                                                             201 Cardiologist                          305 Nutritionist
►Please indicate whether this is a [ ] residence or [ ] business                          202 Chiropractor                          306 Occupational Therapist
                                                                                          203 Dentist                               307 Optometrist
Name:_________________________________________________
                                                                                          204 Emergency Medicine                    308 Physical Educator
Address 1: _____________________________________________                                  205 Family/General Practice               309 Physical Therapist
                                                                                          206 General Surgery                       310 Physician’s Assistant
Address 2: _____________________________________________
                                                                                          207 Internal Medicine                     311 Registered Nurse
City:_______________________ State:________ Zip:___________                               208 Neurologist                           312 Respiratory Therapist
                                                                                          209 Neurosurgeon                          313 Other Health Care Specialist
Country:________________________________________________
                                                                                          210 OB/GYN                                401 Student

  ACSM Membership Categories                                                              Your Value as a Member!
  Option 1                                                                                You have the opportunity to be part of the ACSM global community of experts
  ● Professional and Fellow: ($220) Shall have earned a bachelor’s,                       dedicated to scientific discovery and the rapid, accurate translation of knowledge
     master’s, or doctoral degree at an accredited institution in a field related         into effective applications.
     to health, physical education, or exercise science; or, shall have earned            Your membership allows the College to:
     at least a bachelor’s degree in another area, but be working in fields               ● enrich scientific research of sports medicine and the exercise sciences
     related to sports medicine or the exercise sciences.                                 ● combat inactive lifestyles and the rise of obesity and other chronic diseases
  ● Professional-in-Training: ($155) Shall have earned a terminal degree at               ● certify the knowledge, skills, and abilities of health/fitness and clinical
     an accredited institution in a field related to the exercise sciences or                professionals
     sports medicine and presently be completing a program of residency or                ● position the fields of sports medicine and exercise sciences for even greater
     post-doctoral fellowship.                                                               influence and respect
  ● Graduate Student: ($80) Shall have earned a bachelor’s degree in a                    ● renew our national commitment to physical education and participation in
     field related to exercise science or sports medicine and shall be                       youth sports
     carrying at least one-half of a full academic load, as defined by the                ● change sports policies and practices to increase safety and improve
     attending institution, during at least one semester of a regular academic               performance
     year.
  ● Undergraduate Student: ($80) Shall be a full-time undergraduate                       To do all of this, we need your help. Please take time to join now!
     student in a field related to exercise science or sports medicine.
  Option 2                                                                                If you are mailing your American College of Sports Medicine membership
  ● ACSM’s Alliance of Health & Fitness Professionals: ($90)                              application, did you remember to...
  ● Student Alliance: ($50)                                                               ◗ Make all checks payable to American College of Sports Medicine (if paying by
  International Airmail (OPTIONAL)                                                        check)?
  ● $60 International airmail delivery of publications. ACSM ensures all                  ◗ Include payment for the optional subscription to ACSM’s Health & Fitness
     publications leave the United States within two days of release the                  Journal ®?
     publishers release date.
                                                                                          ◗ Include payment for ACSM Regional Chapter dues?
                                                                                          ◗ Indicate a donation to the ACSM Foundation?
ACSM and FASEB                                                                            ◗ Allow 3-6 weeks to process mailed or faxed memberships?
ACSM is a member of the Federation of American Societies for Experimental
Biology (FASEB), which expands ACSM’s role and position in the science
community. Be sure to watch the ACSM Web site for future updates on ACSM’s
seat at the science policy table.




                                                                               401 West Michigan Street
                                                                               Indianapolis, Indiana 46202-3233
                                                                               FAX: 317-634-7817

				
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