Membership Application
Pennsylvania Athletic Trainers' Society
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Email *
Name: *
Date of Birth (mm/dd): *
Gender:
Home Address:
Street: *
Apartment:
City/State/Zip: *
County: *
Work Address:
Employer/Place of Employment: *
Job Setting: *
Job Title: *
Address Line One: *
Address Line Two:
City/State/Zip: *
County: *
Preferred Mailing Address *
Cell Phone:
Work Phone:
Home Phone:
NATA Membership Number:
If you are a CURRENT NATA member with a PA address, you are automatically a PATS member and do not need to complete this form.
BOC Certification Number: *
Pennsylvania License Number: *
Additional License/Certification:
NPI Number:
School Information
Undergraduate School: *
Graduation Date: *
Anticipated Graduation Date if student
MM
/
DD
/
YYYY
Graduate School:
Graduation Date:
Anticipated Graduation Date if Student
MM
/
DD
/
YYYY
Other Graduate School:
Graduation Date:
MM
/
DD
/
YYYY
Were you referred by a current PATS member?
If "yes", please list their name below:
Membership Category Definitions
Certified Professional: An individual who holds the ATC (Athletic Trainer, Certified) credential and is in good standing.

Associate: An individual, not ATC credentialed or a state licensed Athletic Trainer, who is working in athletic education, research, medicine or other professions related to athletic training. A certified member whose certification is no longer in good standing with the BOC is changed to an Associate member.

Certified Student: A certified individual enrolled as a full time graduate student working towards an advanced degree at an accredited college or university.

Student: An individual enrolled as a full-time student in a college or university who has not fulfilled BOC requirements for certification.

https://www.nata.org/membership/about-membership/member-categories
Membership Category & Payment *
Affirmation *
I hereby apply for membership to the Pennsylvania Athletic Trainers’ Society in the________ category. I will supply ______for annual dues for January 1, to December 31. If accepted as a member of P.A.T.S. it is my desire to advance the Society’s interests and ideals to the best of my ability and to abide by its Constitution and By-Laws.
Required
Make Checks Payable to: PENNSYLVANIA ATHLETIC TRAINERS’ SOCIETY, INC.
Following completion of this form, please mail checks to:
Miranda Fisher
409 Schoolhouse Lane
Shippensburg PA 17257
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