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The Tampa Bay Chapter of the FSMTA
Sports Massage Team
Membership Application
Name: _________________________________________ MA #00____________________
Home address: ______________________________________________________________
City / State / Zip: ________________________________________________________
Phones: Home: (____) ____________________ Work: (____)____________________
Cell (____) _____________ Fax (____) _____________ Pager: (____) _____________
Email address: ________________________________________________________
Massage School: _____________________________________ # years LMT: _______
Sports Massage Therapy Training
School/Program/Workshop ________________________________________________
Check hours: 4-5____ 100____
Have you been a member of a Sports Massage Team? Yes____ No____
Sports Team Name or FSMTA Chapter: _______________________ # years: _______
Are you an
FSMTA Member? Yes____ No____
(Please attach a copy of current FSMTA membership certificate or card)
Are you nationally Certified? Yes____ No____ If Yes
enter your Certificate number: _________________
Do you have professional liability insurance? Yes____ No____
(Please attach a copy of current liability insurance certificate)
Signature: _________________________________________ Date: ______________
For information call Team Coordinator, Pete Pfannerstill, PhD,
LMT at
813-482-7200
Send 1) completed form, 2) proof of FSMTA membership and 3) proof of liability insurance
to:
Pete Pfannerstill, PhD, LMT
3310 Chapel Creek Cir
Wesley Chapel, FL 33544-7702
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