Arizona Association of School Psychologists

Membership Renewal JULY 1, 2008 - JUNE 30, 2009

Thank you for renewing you membership in AASP. If your membership has lapsed more than two years, please use the New Membership Application. Student members should use the New Membership Application each year.

Please complete the registration form below.
Fields marked with an asterisk are required. Thank you.

Registration Type

Full Member $75.00 Associate Member $75.00 Retired Member $40.00

Required Applicant Information

*Title
Dr. Mr. Mrs. Ms.
*Name
*Home Address
*City	*State	*Zip/Postal Code
Home Phone
*Employer
*Title/Position
*Office Address
*City	*State	*Zip/Postal Code
*Office Phone 1
Office Phone 2
*Office Fax
*Email
Preferred Mailing Address
Work	Home
Are you the lead psychologist for your district?     Yes     No
I do not wish this email address to be added to the listserv. I do not wish to have my information printed in the AASP Directory, which is distributed only to AASP members.

Optional Additional Information

Are you multilingual? Yes No Which language(s)?

Are you a Nationally Certified School Psychologist (NCSP)? Yes No

Primary Work Setting? Preschool Elementary Middle School Secondary Alternative University Administration Hospital/Clinic Private Practice

Licensure: Psychologist/AZBPE        Counselor/PCL

Participation in AASP:

I would like to participate on a committee. Yes, call me @ Not at this time Areas of committee interest. Communications Ethics and Professional Standards Professional Development Child and Family Advocacy Other I would like to be considered for a leadership positionin AASP.

Biographical/Demographical:

Age 20-30 31-40 41-50 51-60 over 60

Gender: Female     Male

Ethnicity:

American Indian or Alaska Native Puerto Rican Asian-American or Pacific Islander Other Hispanic/Latino Black/African-American White/Caucasian Chicano/Mexican-American Other

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