_____________ / / Name Date Address City, State, Zip Code Phone Phone (H/M/O) (HOME/MOBILE/OFFICE) Primary Secondary Preferred email address: _______________________ Place of employment: ______________________________ Position: Year joined MoATA NPI Number ____________________________ NATA Member Number BOC Certification Number Licensed to practice in Missouri: Y N Primary practice setting: College/University High School Clinic Clinic/HS Professional Other Student Retired Not currently employed as AT Please rank your TOP THREE choices for committee or work group membership. Please note that selecting a committee does not ensure your placement on a committee. You will be notified of appointment to a particular committee by the committee chair Governmental Affairs Committee College/University Athletic Training Student Honors and Awards Committee Committee Young Professionals Committee Advisory Secondary Schools AT Committee Committee Committee on Professional Advancement Professional Meeting Committee Public Relations College/University Committee NATA Research and Education Foundation Other Work groups for strategic planning projects Member Involvement - Increase member participation Relationship Building - Build new relationships and strengthen existing relationships with other organizations, legislators, and supportive groups Revenue Issues related to reimbursement and recognition for all athletic trainers – Please attach a brief introduction of yourself, your career accomplishments/interests, and skills that you would bring to a committee appointment or work group Send this form and your letter to: MoATA President Karen Fennell at finney825@yahoo.com
Name _____________ Date / / Address City, State, Zip Code Phone (HOME/MOBILE/OFFICE) Phone (H/M/O) Primary Secondary Preferred email address: _______________________ Place of employment: ______________________________ Position: Year joined MoATA NPI Number ____________________________ NATA Member Number BOC Certification Number Licensed to practice in Missouri: Y N Primary practice setting: College/University High School Clinic Clinic/HS Professional Other Student Retired Not currently employed as AT Please rank your TOP THREE choices for committee or work group membership. Please note that selecting a committee does not ensure your placement on a committee. You will be notified of appointment to a particular committee by the committee chair Governmental Affairs Committee Honors and Awards Committee Young Professionals Committee Advisory Committee Professional Meeting Committee College/University Committee College/University Athletic Training Student Committee Secondary Schools AT Committee Committee on Professional Advancement Public Relations NATA Research and Education Foundation Other Work groups for strategic planning projects Member Involvement - Increase member participation Relationship Building - Build new relationships and strengthen existing relationships with other organizations, legislators, and supportive groups Revenue – Issues related to reimbursement and recognition for all athletic trainers Please attach a brief introduction of yourself, your career accomplishments/interests, and skills that you would bring to a committee appointment or work group Send this form and your letter to: MoATA President Karen Fennell at finney825@yahoo.com
Interest-Form-2017.docx