KCRA membership application

*This application for membership is for January 1, 2008-December 31, 2008. If you joined KCRA at the end of 2007, you will need to renew at this time.

Please make checks payable to K.C.R.A and mail to:
Peggy Cox, RN, RRT,
Frazier Rehab Institute
220 Abraham Flexner Way
Louisville, KY 40202
Questions?
Contact Peggy Cox at
peggy.cox@jhsmh.org
or
ph: (502) 582-7620

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.
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Date of Birth:
First Name:
Last Name:
E-mail Address:
Preferred Mailing Address	Home Work
Street Address:
Address continued:
Apt #:
City:
State:
ZIP:
Phone:
Fax:
Degree(s):
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 What is 3 + 3 (This is a Security Question to prevent Spam)
Membership Type	AACVPR Member ($20/year KCRA Membership fee. Please include a copy of current AACVPR membership card) Non AACVPR Member ($25/year KCRA Membership fee.) Student ($10/year KCRA Membership fee. Please include a copy of your current student ID)

If you selected other for either Current Involvement or Professional Affiliation please explain below...

Your information will not be sold or shared with anyone outside of AACVPR affiliate societies.

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