Please print this application and mail it to:
Baptist Health Baptist Memorial Medical Center
Attn: Sue Manning
Cardiac Rehabilitation
3333 Springhill Drive
North Little Rock, AR 72117
MEMBERSHIP APPLICATION
Please Print
Name:_______________________
Home Address:________________________________________
City:__________________State:__________Zip_______________
Home Phone:(___)______________Work:(___)______________
e-mail _______________@_________________________
Institution:_______________________________________
Address:_________________________________________
City:____________________________________________
State:_________________________Zip________________
Position/Title:______________________________________
Program Services: ____
Cardiac Rehabilitation
____ Pulmonary Rehabilitation
____ Wellness/Prevention Program
____ Other _______________________
Membership Fee:
______Professional $10.00
______Associate $10.00
______Student $10.00
Make check payable to: AVCPRA
Please contact me regarding the following:
President ____ Vice President ____ Secretary ____
Treasurer ____ Reimbursement ____ Webmaster ____
Outcomes Committee ____ Annual Workshop Committee ____
Research Committee ____ Public Relations Committee ____
Newsletter Editor ____ Program Listings Editor ____
Program Certification ____
Reimbursement Committee ____