ACSM | Health & Fitness Summit & Exposition Registration Form

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9 TRACKS BRIDGING THE GAP BETWEEN SCIENCE AND PRACTICE^®

REGISTRATION AND BADGE INFORMATION

(Badge information is limited to 30 characters per line)

Current ACSM/Alliance Member?	Yes	No
Current ID#:
Is this your first summit?	Yes	No
I Attended In:
Have you ever been a member of ACSM?	Yes	No
Previous ID#:

ACSM Certified Which Certification?
Gender*:	Prefix*:

Last Name*:
First Name*:
Badge Name*:
Institution:
Address*:
City: State: Zip:
Country: (If Not U.S.)
The Above Address is My*:
Is This a Change of Address?*:
Home Phone*:
Work Phone*:
Fax:
Email*:
Date of Birth*:
Highest Degree Earned*:

fields designated with * are required for submission.

By clicking Submit below you authorize that the above filled out information is accurate and authorize your credit card to be billed the total amount owed.

MAJOR RESPONSIBILITY (CHECK ONE):

1. Health Fitness Instructor/Personal Trainer
2. Fitness Program/Wellness Program
3. Cardiac Rehabilitation/Exercise Specialists
4. Club Owner/Manager
5. Educator
6. Physical Therapist/Nutritionist/Nurse
7. Student
8. Physician
9. Athletic Trainer
10. Other

WOULD YOU LIKE A ROOMMATE?

Yes No

If Yes, we will forward a list of potential roommates for you to contact

STUDENTS:

Would You Like to Receive Information On the Student Volunteer Program?*

Yes No

PAYMENT INFORMATION:

Summit Attendance Fee (from above)...........

Preconference Fee (from above)...........

One Day Attendance Fees (indicate day below)

Monday ($90)	Tuesday ($170)
Wednesday ($170)	Thursday ($90)

TOTAL

PAYMENT:

Full Payment Must Accompany Form
U.S. Dollars only. ACSM Federal I.D. #23-6390952

Card Type:
Card #:
Expiration Date:	(MM/YYYY)
Name On Card:

PREREGISTRATION ENDS FEBRUARY 23, 2009. THEREAFTER, REGISTRATION WILL BE ACCEPTED ON-SITE.
GENERAL INFORMATION: Please notify ACSM by February 23, 2009, if you need any special accommodations as a result of disability. The planner and sponsors of this event claim no liability for the acts of any suppliers to this meeting, nor for the safety of any attendee at or while in transit to this event. The planners and sponsors reserve the right to cancel this event without penalty. Attendees who purchase non-refundable airline tickets, do so at their own risk. The total amount of any liability of the planners and sponsors will be limited to a refund of the registration fee. Your submission of this form acknowledges acceptance of these terms. CANCELLATION POLICY: Cancellations will be accepted if sent in writing to the ACSM National Center and postmarked by February 23, 2009. A $50 service charge will be applied to all cancellations. Refunds will not be issued to cancellations made after February 23, 2009. All refunds will be made after the meeting (membership dues are not refundable).SUMMIT WAIVER: I agree to hold harmless the American College of Sports Medicine (ACSM), NASM, Health & Fitness Summit

presenters, sponsors and staff, from any and all liability arising out of workouts or activity sessions at this event. This includes, but is not limited to, muscle strains, tears, pulls, broken bones and illness or loss to my person or property. I understand the risks involved in participation in interactive, strenuous activity and attest that I am in sound physical condition. Your submission of this form acknowledges acceptance of these terms. IMAGE/LIKENESS/VOICE RELEASE: I understand and agree that, as a result of participating in ACSM’s Health & Fitness Summit & Exposition, my image, likeness or voice may be recorded by photography, video or other medium. I hereby grant irrevocable and unrestricted permission to ACSM and its representatives or assignees to use my image, likeness or performance in any medium and for any purpose. I hereby waive any right to inspect or approve such use or materials. Your submission of this form acknowledges acceptance of these terms. CECS/NATA (CONTINUING EDUCATION CREDITS, NATIONAL ATHLETIC TRAINING ASSOCIATION): ACSM CEC verification will be available online, instructions will follow meeting attendance. Exhibitors, guests and media must register as an attendee to be eligible for credit.

* Student Volunteer Program: Calling all students! Volunteers are needed to assist with a variety of tasks including registration duties, restocking inventory, assisting with sessions, etc. Shifts are a minimum of four hours long, and student volunteers will receive a refund of 1/2 the student registration fee post meeting! If you are interested, please check the appropriate box on this form. Students will be contacted on a first come, first-serve basis, so be sure to register early! (Limited number of slots available)

Before 1/1/09	1/1/09- 1/30/09	1/30/09- 2/23/09	On-site Fee	SUMMIT ATTENDANCE CATEGORIES
$385	$410	$440	$470	NASM or ACSM Certified Professional*
$175	$200	$230	$230	NASM Student Member* (verification of student ID on-site)
$435	$465	$495	$525	Non Members
FOR SINGLE DAY FEE SEE PAYMENT INFORMATION BELOW
$100	ADD ONE PRECONFERENCE (OPTIONAL) - Summit Attendees Only
3/25/09	Worksite Health Promotion: From Policy to Practice
3/25/09	Women's Health Across the Lifespan
3/25/09	The Final Chapter of Follow the Evidence, Not the Guru's (NASM)
ACSM MEMBERS REGISTER AT WWW.ACSM.ORG/REGISTER