NCEMSF - Membership

Sign Me Up!

Thank you for choosing to become a personal member of NCEMSF.

Please use the form below to send us your membership information. Blue fields marked with asterisks(*) are required. When finished, press "submit info" at the bottom of the page.

After filling out this application, you'll have the opportunity to select your payment method. We accept checks, Visa, MasterCard, Discover, and American Express. For your security, credit card payments are processed through PayPal. You can also use this registration form if your personal membership is part of an Institutional Value Pack or if you are registering for an NCEMSF conference.

Personal Membership Application

Name:

First:*

Middle: Last:*

Salutation:

Suffix: (Jr., III, R.N., Ph.D., M.D.)

Account Identification: (Your NCEMSF login will be your e-mail address.)

E-mail Address:*

Confirm e-mail Address:*

Initial Password:*

Must be 5-15 alphanumeric characters. It is not case sensitive.

Retype Password:*

(for security reasons)

Campus / Academic Address:

Street 1:*

State / Province:*

Street 2:

Zip / Postcode:*

City:*

Country:*

Phone:*

Home / Permanent Address:
(Check this box if same as Campus / Academic address: )

Street 1:*

State / Province:*

Street 2:

Zip / Postcode:*

City:*

Country:*

Phone:*

Preferred Address:

Preference:

By default, NCEMSF mail during the academic year is sent to the campus / academic address, and mail during the summer is sent to the home / permanent address. You may change this by designating your preferred address.

About you:

University / Affiliation:

Affiliation:
(if not listed above)

Title / Position:

Level of Training:

Graduation Year:

Current students: use your expected graduation
Alumni: use your highest degree graduation year

Alumni Status:

Are you a graduated (retired) alum of a campus EMS organization?

Major Category:

(for reporting purposes)

Major:

Career Plans:

Privacy Information: (Please review our privacy policy)

Keep Info Private:

NCEMSF may occasionally make its mailing list available to other organizations. Please select "yes" if you wish to be omitted from these distribution lists. Note: selecting "yes" will exclude you from certain membership benefits, such as the free subscription to EMS Magazine. You may change your preference at any time in the future.

EMS Magazine Subscription:

	One of the member benefits of joining NCEMSF is a free one-year subscription to EMS Magazine. Postal regulations require that you explicitly request this benefit annually. Please indicate whether you would like to receive a free EMS Magazine subscription. This benefit applies to US residents only.
	To confirm that you would like an EMS Magazine subscription, the publisher requests a "personal qualifier," so we'll also need your four-digit year of birth.

Current Academic Year Dues Rates:

Desired Category:*