<p> 2013 Texas ACSM Annual Meeting Feb. 28-March 1, 2013 University of Texas J.J. Pickle Research Campus Austin, TX</p><p>REGISTRATION FORM</p><p>Name: </p><p>Badge Name: (Enter name as it should appear on your badge.) Professional Affiliation (e.g., University, Hospital, etc.): </p><p>Address: </p><p>City: State: Zip: </p><p>Home/Cell Phone: Work: </p><p>E-mail: </p><p>Highest Degree: FACSM: Yes No Gender: Male Female</p><p>ACSM Interest Area (“X”one): Basic/Applied Science Medicine Education/Allied Health Health Fitness Alliance</p><p>ACSM Occupation Code (enter one from below): (All Students = 401)</p><p>101 Anatomist 117 Veterinarian 210 OB/GYN 304 LPN 102 Applied Physiologist 118 Other Basic/App. Sci 211 Ophthalmologist 305 Nutritionist 103 Biochemist 201 Cardiologist 212 Orthopaedic Surg. 306 Occupational Therapist 104 Biomechanist 202 Chiropractor 213 Pediatrics 307 Optometrist 105 Coach 203 Dentist 214 Physiatrist 308 Physical Educator 106 Ergonomist 204 Emergency Medicine 215 Podiatrist 309 Physical Therapist 107 Exercise Biochemist 205 Family/General Practice 216 Psychiatrist 310 Physician’s Assistant 108 Exercise Physiologist 206 General Surgery 217 Radiologist 311 Registered Nurse 115 Kinesiologist 207 Internal Medicine 218 Other Medicine 312 Respiratory Therapist 116 Sports Psych./Sociologist 208 Neurologist 301 Athletic Trainer 313 Other Health Care Spec. 209 Neurosurgeon 302 Kinesiotherapist 401 Student 303 Health Educator 501 Health & Fitness Prof. </p><p>Membership Type (“X”one): Student Professional-in-Training (Post-docs, Residents, etc.) Professional Physician Registration Category (Please “X” the category that applies to you.): #1: CURRENT Texas ACSM member REGISTERING for the annual meeting ONLY (i.e., Texas ACSM membership is not due for renewal before March 1, 2012 or will be renewed through ACSM national before that date.).</p><p>Select option #2 if you paid your membership at last year's conference. #2: CURRENT Texas ACSM member REGISTERING for the annual meeting and RENEWING Texas ACSM membership at this time.</p><p>#3: NON-Texas ACSM member REGISTERING for the annual meeting.* # </p><p>Based on your membership type and registration category, determine and circle your appropriate registration fee on the table below. NOTE: ACSM members with emeritus status should contact Dr. Brian McFarlin at [email protected] or 940-565-2545 for registration information. Category #1: TACSM member+, Pre-registration On-Site meeting registration only. Postmarked by 2/14/13 Registration Student $20 $35 Professional-in-Training $35 $65 Professional $65 $100 Physician $130 $165 Category #2: TACSM member+, Pre-registration On-Site meeting registration and Postmarked by 2/14/13 Registration membership renewal. Student# $35 $50 Professional-in-Training# $50 $80 Professional# $100 $135 Physician# $165 $200 Category #3: Non-TACSM Pre-registration On-Site member, meeting registration. Postmarked by 2/14/13 Registration Student* # $ 20 $35 Professional-in-Training# $50 $80 Professional# $100 $135 Physician# $165 $200 *Students registering for their first TACSM conference receive their first year of TACSM membership free. #Fee includes TACSM membership for one year. +If TACSM membership expires prior to March 1, 2013, membership renewal is required with registration.</p><p>Yes No Do you require any special assistance and/or dietary restriction to fully participate in this conference? If you replied “YES,” a TACSM staff member will contact you prior to the meeting to discuss accommodations.</p><p>For PRE-REGISTRATION, please mail completed registration form and cash, check or money order (payable to TACSM) for the appropriate amount to: Brian McFarlin, Ph.D., FACSM TACSM President University of North Texas Physical Education Bldg, Room 209 Denton, TX 76203 PRE-REGISTRATIONS MUST BE POSTMARKED BY FEBRUARY 14, 2013. PRE- REGRISTRATIONS POSTMARKED AFTER THIS DATE WILL NOT BE PROCESSED.</p>