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ATPC Registration Form
 
AMSSM 19TH ANNUAL MEETING REGISTRATION
 
Full name:
Degree:
  Preferred Email Address:
  Email Address to Send a Copy of the Receipt:
 Full Mailing Address (Please include City, State, Zip)
  Preferred Phone
  Fax
  Badge Information - Name on Badge: 
  Company/Affiliation (Please include name, address, city,
  state & zip code):
 
 Dietary or Physical Requirements:
   (Please list if you have any physical or dietary requrements
   which require accommodation in order to fully partiipate in this
   activity.)
  Please select from the societies listed below which one
  you are a current member:
AMSSM Member ACSM Member AOSSM Member
  Specialty (Please check one box only)
Emergency Medicine
Orthopaedic Surgery
Family Medicine
Physiatry
Internal Medicine
Pediatrics
Other:

  Team Physician (Check each applicable box):
  High School
  Collegiate
  Professional
  Olympic/Elite
  Other:
  
  Registration Fee Schedule - Please select the appropriate 
  category from the drop down menu  below (Individuals in a
  fellowship program can register at a discounted fee - a letter from
  your  fellowship stating you are a current fellow is required and
  can be emailed to mlane@amssm.org

 
How many Advance Team Physician Courses have you attended?  
What years did you attend? 
Trusted Commerce 
Payment Type:
Please make check payable to AMSSM, to be mailed separately - Please indicate on check that payment is for membership and must include applicant’s name.
Mastercard Visa Discover
Name as it appears on credit card:
CVV (located on back of card) Expiration Date: