Athletic Trainer Compliance Form

 

1 Start 2 Complete

Full Name *

Mobile Number: *

Email Address: *

Home Address *

School Name: *

My status as a Licensed Athletic Trainer in the state of North Carolina as shown on the North Carolina Board of Athletic Trainer Examiners website is: *

Active

Expired

My license number as shown on the North Carolina Board of Athletic Trainer Examiners website is: *

My city of residence as shown on the North Carolina Board of Athletic Trainer Examiners website is: *

I am employed full time by the LEA: *

With teaching responsibilities

Without teaching responsibilities

N/A

I am employed by a medical or university facility and serve _____ *

FULL TIME as an athletic trainer to a NCHSAA member school

PART TIME as an athletic trainer to a NCHSAA member school

N/A

The information contained in this verification statement is a true and accurate statement of my standing as a Licensed Athletic Trainer in the state of North Carolina. *

Confirm

My status as a Licensed Athletic Trainer in the state of North Carolina as shown on the North Carolina Board of Athletic Trainer Examiners website is “Active”. *

Confirm

I am aware that falsification of this information contained in this report may result in the suspension of my ability to serve in the role as a Licensed Athletic Trainer for the 2022-2023 school year. *

Confirm