Name of Nominee:
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Home Address
Street:
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City:
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State:
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Zip:
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Home Phone:
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School Address
Street:
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City :
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State:
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Zip:
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School Phone:
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NATA District:
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| Athletic Training Experience: |
School (Place of Employment)Years(Enter Below):
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Number of Years Nominee has had Supervision of ATSA’s (Enter Below):
Formal Class Instructor, Club Advisor, etc…
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ATSA’s who are now Medical Professionals
Enter one of the following Choices: (1 – 3), (4 – 6), (7 or Above)
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| ***Please list all of the candidate's former ATSAs who have become heatlhcare professionals and the number of years they've been in the profession (Enter Below): |
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Additional Experience:
Prom chaperone, Powder Puff Game
coverage, Senior Trip chaperone,
Staff development instructor (CPR, etc..),
develop conditioning programs for
teams/students, etc…
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| List the outstanding accomplishments of the candidate’s athletic training career. If additional space is needed, please submit additional papers... |
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Name of Nominating Representative:
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Title:
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