Membership Application





Last Name (required):
First Name (required):
Certification Agency (required):
Certification or Student No. (required):
Certification Agency:
Certification No.:
Certification Agency:
Certification No.:
ASRT No. (if applicable):
I wish to be contacted about future events and CE seminars
YesNo
Mailing Address (required)
Address 1:
Email (required):
Address 2:
City:
State:
Zip:
Island:
Are you interested in volunteering or assisting the HSRT with administrative procedures at CE seminars or volunteering on your respective Island?
YesNo
How did you hear about HSRT?

Please submit this form electronically by selecting the SUBMIT button below or mail it to:

Hawaii Society of Radiologic Technologists
PO Box 1675
Pearl City, HI 96782

 
DISCLAIMER: You understand and agree that becoming a member of the Hawaii Society of Radiological Technologists (HSRT) is exclusive only to those entities who have been determined to be in the medical imaging profession. This determination in made exclusively by the board of directors of the HSRT or its appointed designee.

The HRST to the fullest extent permitted by law, disclaims all warranties and will not be liable for any damages, whether direct, indirect, special, consequential, incidental or punitive damages, resulting from or related to your membership or denial of membership, services or benefits you receive or fail to receive from the organization, whether based on warranty, contract, tort, or any other legal or equitable theory, and whether or the HSRT has been advised of the possibility of such damages.

By joining the HSRT, you agree to defend, indemnify, and hold harmless the HSRT and its officers, directors, employees, representatives and agents, from and against any and all losses, claims, damages, costs and expenses related to your misrepresentation as to any information provided to the organization, your breach of any of these Terms or any misuse of any goods, services or other benefits of the HSRT membership.  All membership information is for the sole use of the HSRT and will not be sold to third parties.  Distribution to third parties will only be permitted to the ASRT for annual membership reporting requirements.