E-MAT Resister Form EN E-MAT Register Form Please enter your information into the form below.All fields marked “∗” must be completed. entry form (Information of the representative's) *Full name: *Email: *Email(For confirmation): *Work Place_Facility Name: *Job Category: Physician Nurse Physical Therapist Occupational Therapist Speech - Language Pathologist Nutritionist Researcher Other If you choose ”other” in the above, please enter the information in the form below. If you choose "other" in the above, please enter information in the form below. JSEM will send the E-MAT sticker. Please fill in the below. *Address Line 1: Address Line 2: *City State Zip Code *Nationality E-MAT Configuration Requirements E-MAT members must be healthcare staff E-MAT teams must comprise three or more members from two or more professions Physician Number of persons: 0 1 2 3 4 5 6 7 8 9 10 Nurse Number of persons: 0 1 2 3 4 5 6 7 8 9 10 Physical Therapist Number of persons: 0 1 2 3 4 5 6 7 8 9 10 Occupational Therapist Number of persons: 0 1 2 3 4 5 6 7 8 9 10 Speech-Language Pathologist Number of persons: 0 1 2 3 4 5 6 7 8 9 10 Nutritionist Number of persons: 0 1 2 3 4 5 6 7 8 9 10 Researcher Number of persons: 0 1 2 3 4 5 6 7 8 9 10 Other Number of persons: 0 1 2 3 4 5 6 7 8 9 10 If you choose "other" in the above, please enter information in the form below. Check & Send