SEACSM Clinical Meeting Registration form
SEACSM Clinical Meeting Registration Form
WE are allowing individuals that will be attending ONLY the clinical program for SEACSM Annual meeting to use the following registration form found below. Please provide all of the requested information. There is no registration fee for individuals that will be attending ONLY the clinical program at the SEACSM Annual Meeting. You must pre-register to take advantage of this special registration.
However, those interested in attending the remainder of the general SEACSM Meeting must submit a completed registration form and proper registration fees for the meeting. See this page for the link for complete information:
SEACSM 2012 Meeting Registration information
Clinical Registration Form:
Please check to see that you've entered all of the information, before selecting the "Submit Responses" at the bottom of the page. Your information on this form will then be e-mailed to Clinical Committee of SEACSM. Looking forward to your registration materials.
Clinical Registration Form
Badge Name:
First Name:
Last Name:
Contact Information:
Professional Affiliation or Institution:
Street Address:
City:
State:
Select one
AL
FL
GA
KY
LA
MS
NC
SC
TN
VA
Other-out-side of SEACSM
Zip:
Phone(area)+Number:
E-mail address:
Special Events:
Select one
Friday evening Reception
Saturday afternoon SEACSM Chapter Luncheon
Both Events
Neither
Primary Interest Area (Select one):
Select one
Adult Fitness
Athletic Training
Biomechanics/Kinesiology
Cardiology/Cardiac Rehabilitation
Emergency Medicine
Internal Medicine
Nursing
Nutrition
Orthopedic Medicine
Orthopedic Surgery
Pediatrics
Physical Therapy
Family Medicine
Other
Profession (Select one):
Select one
MD
DO
ATC
PT
NP
PA
Other
Meeting Info (Select one):
Select one
This is my first SEACSM Clinical Meeting
I have attended two or more SEACSM Clinical Meetings
To prevent automated submissions, please enter the code as it is shown below:
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Please check to see that you have entered information in all of the requested boxes. You are now ready to submit your information: