Member Info

Please use the information below to apply for a membership with TSSCVPR.

All Required fields MUST be filled in in order to submit, including the checkboxes.

General Information
* First Name
Middle Name
* Last Name
* Job Title
Degree/Credentials
Referred by
* AACVPR member?


Institution Information
* Institution Name
* Address
* City
* State
* Zip
* Phone
Fax
* E-Mail (Work)

if work email not available please enter personal email.
Website


Home Information
* Address
* City
* State
* Zip
* Phone
Fax
* E-Mail (Personal)

if personal email not available please enter work email entered above.
Membership Information
* Local Chapter Affiliation
* Work Area - Check all that apply









* Job Responsibilities - Check all that apply:





























Membership Type
* Membership Fee:

$10 Student Member - documentation of full time status required

$45 Individual Member for 2017

$80 Two year membership for Jan. 1, 2017 - Dec. 31, 2018

Registered Until:  
* Membership Agreement:

I agree to abide by the Code of Ethical and Professional Conduct of the Tri-State Society of Cardiovascular and Pulmonary Rehabilitation. Visit the TSSCVPR website for the code of ethics. (TSSCVPR.org)



* Required Field