Texas Association of Cardiovascular and Pulmonary Rehabilitation

Texas Association of Cardiopulmonary Rehabilitation
Membership Application

For information about our member recruitment program click here.

Please complete the following:
First Name:
Last Name:
Nickname:
Company / Facility Name:
Name of Program:
Title:
Discipline(RN, EP, etc):
.
Work Information
Work Address:
Work City:
Work State:
Work Zip Code:
Work Phone:
Work Fax:
.
Home Information
Home Address:
Home City:
Home State:
Home Zip Code:
Home Phone
.
Fax
Email Address:
Member of AACVPR

RAP (Refer-A-Pal) Program
Were you referred to us by another member?
If so, whom:
Program Information: Please check all that Apply:
Program Manager:
Contact Phone:
Email:
Cardiovascular Rehab	Pulmonary Rehab
Inpatient	Inpatient
Outpatient	Outpatient
Hospital Based	Hospital Based
Free Standing	Free Standing
.
Please check one membership category and complete the following.
Member ($40/year \| $30 before 2/14)
Physician, Medical Scientist, Allied Health Professional, Educator, and/or Nurse involved in some aspect of cardiovascular and/or pulmonary rehab.
Degree(s):
Principle field of education:
Certification(s)/License(s):
.
Student Member ($10/year)
Undergraduate or graduate student currently enrolled in a medical or allied health curriculum with a minimum of 6 hours interested in cardiovascular and/or pulmonary rehabilitation. No voting priveleges granted. Must mail or fax a copy of your student ID to TACVPR.
Institution:
Major:
Anticipated Graduation Date:
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Payment information will be collected on the following screens!