Membership Application:
The Committee on Ethics and Credentials and the executive officers may accept any chiropractic physician,
who meets the licensure requirements of the state of Florida and is a member of the FCA in good standing, for
membership in this Council upon approval. We reserve the right to verify malpractice coverage and credential
each doctor prior to any even coverage.
NAME: ___________________________________
Office Name/Address:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Office Number:____________________________
Cell Phone Number:________________________
Email Address:____________________________
Graduate School Attended:_________________
Years in Practice:_________________________
Do you carry malpractice insurance? YES NO
Have you ever been sued or are you currently in litigation for a malpractice claim? YES NO
Have you ever covered a sports medicine event? YES NO
Are you a member of: FCA ACA ACASC FICS ACSM Other_________________
Please submit a copy of your current malpractice declaration page, a current Curriculum Vitae with a check in the amount of $100.00
made payable to FCASC along with your application to:
FCA Sports Council Membership
Sabrina Atkins Bathalter, DC
7513 West Sand Lake Road
Orlando, Florida 32819
Please note yearly membership dues are $100.00. Student membership is free. Vendor membership is $200.00 per year. Student and vendor memberships are non-voting
memberships.