Albany Teaching Day Registration "*" indicates required fields 1Registrant Information2Survey3Payment Information AARC NumberYour AARC member number is required for membership discount. Your AARC card may also be requested at registration.Name* First Last Credentials AE-C CPFT CRT CRT-NPS CRT-SDS CSE CTTS DO EMT-P LPN LVN MD RN RPFT RPSGT RRT RRT-ACCS RRT-NPS RRT-SDS Other Education Credentials AA AAS AS BA BHS BS BSEd BSN BSRC BSRT DHSc EdD JD MA MBA MEd MHA MHS MPA MPH MS MSEd MRC MSRC MSA MSJ MSN PhD Other Honorary Credentials FAACVPR FAARC FACHE FCCM FCCP Other Other CredentialsThis field is for special or educational credentials you would like on your name badge.Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*CountyAlbanyAlleganyBronxBroomeCattaraugusCayugaChautauquaChemungChenangoClintonColumbiaCortlandDelawareDutchessErieEssexFranklinFultonGeneseeGreeneHamiltonHerkimerJeffersonKingsLewisLivingstonMadisonMonroeMontgomeryNassauNew YorkNiagaraOneidaOnondagaOntarioOrangeOrleansOswegoOtsegoPutnamQueensRensselaerRichmondRocklandSaratogaSchenectadySchoharieSchuylerSenecaSt. LawrenceSteubenSuffolkSullivanTiogaTompkinsUlsterWarrenWashingtonWayneWestchesterWyomingYatesEmail* Enter Email Confirm Email Please provide a method to contact you in the event of special conference announcements. A registration confirmation email will be sent to this address. Duplicate email addresses are not accepted.Phone numberEmployment InformationJob functionSelect choiceManager / DirectorSupervisorEducatorStaff therapist / technicianSales / marketingStudentOtherJob settingSelect choiceAcute care / hospitalCollege / universitySubacute / long term careHome CareSleep labPhysician officeIndustryPFT labOther Where did you hear about this conference? NYSSRC website Facebook Twitter Email Friend Other Payment, Terms and ConditionsTerms and Conditions*+ Non-members may join the AARC at the workshop. The difference between the regular fee and the discounted fee will be applied to the AARC membership. + Early registration is available through February 14. Beginning February 15, the fee increases $15. + No refunds after February 21. + Payment is made via credit / debit card or PayPal. We accept Visa, MasterCard, or American Express through our secure online payment processing. Only institutional checks will be accepted. No personal checks. + Payment by institutional checks must be received by February 21 or your registration may be voided. + Click for our conference cancellations / refunds / privacy policy. + Photographs taken during the conference may be used in future NYSSRC publications and promotions. + There will be a $5.00 processing fee for all refunds. + Any questions please contact us at info@nyssrc.org. I agree to the Terms and Conditions Early Registration fee*Select choiceAARC MemberNon-memberStudentRegular Registration fee*Select choiceAARC MemberNon-memberStudentCoupon Committee and board members enter code.Total Payment choice*Choose method of paymentCredit / Debit CardPayPalInstitutional CheckCredit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name When you click submit, you will be directed to the PayPal website to complete your payment. Once your payment is complete, you will be redirected back to the NYSSRC website for a confirmation message.Institutional Payment InformationPayment made by institutional check requires the below information. Complete the fields below for the institution that will be issuing the check for this conference. Do not use your personal address.Institution Name* Facility name Department Name* Department or division name Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberNameThis field is for validation purposes and should be left unchanged.
