Full Name:* First Last Check all that apply:* PhD MS MA MPH RD/RDN LDN DTR Undergraduate Student Graduate Student Other If other:Date of Birth*Please enter your date of birth. This will be used to determine eligibility for KAND awards if you receive a nomination. Please select today's date if you do not want to supply your date of birth. MM slash DD slash YYYY When did you become a dietitian?*If you do not know the exact date, use the first as the day of the month and submit an accurate month and year. This will be used to determine eligibility for KAND awards if you receive a nomination. MM slash DD slash YYYY Main Phone:*Secondary Phone:Email:* Address:* Street Address Address Line 2 City State 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 ZIP Code Place of Employment:Work Address: Street Address Address Line 2 City State 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 ZIP Code Job Title:Work Phone:Media OpportunitiesIf you are interested in helping KAND with media inquiries, please list topic areas you are comfortable covering and any previous experience working with the media. Previous experience is not required.Volunteer Opportunities - UNSA/KAND Student Mentoring Network I am a RD and am interested in learning more about serving as a mentor for nutrition students. I am an undergraduate student and am interested in learning more about being mentored by local RDs. I am a graduate student and am interested in learning more about being mentored by local RDs. AND Membership InformationPlease check the type of Academy of Nutrition and Dietetics membership that best describes you.AND Membership Type:* RD/RDN Associate DTR Retired Student Other Not an AND Member If you are an AND member, please provide your membership number.*KAND Membership DuesType of Membership:*AND/KAND Membership - $25Retired Membership - $10Student or 1st year RD/DTR Membership - $10NON-MEMBER Friend of KAND Membership - $35AND/KAND Membership with KAND T-shirt - $45Retired Membership with KAND T-shirt - $30Student or 1st year RD/DTR Membership with KAND T-shirt - $30NON-MEMBER Friend of KAND Membership with KAND T-shirt - $55All types of members are eligible to receive CEU's. Only AND/KAND and retired members have full voting privileges. The "Friend of KAND" option is not a membership. A Friend of KAND is a Knoxville area dietitian or other interested professional who wishes to attend meetings only for the purpose of obtaining CEU. Any dietitian is invited to attend and obtain 1 CEU for $10.00, or they may pre-pay for the Friend of KAND discount and attend all the meetings with CEU for $35.00. Friends of KAND will receive KAND meeting and organization emails, but will not have voting privileges or access to the KAND membership directory. T-Shirt Size (optional)SmallMediumLargeExtra LargePlease choose your shirt size if selecting a membership/t-shirt bundle.Payment Method:* Credit Card - Preferred Mail in Check Billing Address:* Street Address Address Line 2 City State 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 ZIP Code Credit CardCard Details Cardholder Name Please fill in the rest of the form and click 'Submit' to complete. Then mail your payment to: KAND Membership Drive PO box 50142 Knoxville, TN 37950-0142 This field is hidden when viewing the formHidden SectionsCredit Card Info:* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name This field is hidden when viewing the formHome Phone: Δ
