Wisconsin School Psychologists Association, Inc.

New Member Application Form
Membership for September 15^th, 2011-September 14^th, 2012

Region:

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Membership:

Full Member ($60)Leave ($30)
Intern Member ($40)Associate Member ($30)
Life Member (free)Student ($20)

Name:

First:

Last:

My name has changed

Address:

This is a new address

City

State

ZIP

Email:

Note: Many school district email accounts block messages from outside agencies such as WSPA. In order to insure your receipt of messages from WSPA, please include an email address that is not likely to be blocked.

Home Phone:

Work Phone:

Employer:

Certification:

Check all that apply.
I am a Nationally Certified School Psychologist.
I hold a Professional Psychologist Licensure.

I hold a WI School Psychologist
       Private Practice License.I hold a DPI School Psychologist License.

I am a member of WAPSO
       (Alliance of Pupil Services).I am a member of NASP.

I am a member of WSCA
       (School Counselors).I am a member of WCASS
       (Alliance of Special Services).

Volunteer:

I want to join the WSPA Board or a WSPA Committee, please contact me.

WSPA periodically participates in membership exchange promotions with NASP for the purpose of inviting Wisconsin NASP members to join WSPA if they are not active members. In return, WSPA shares members’ names, addresses, and emails with NASP so that WSPA members can be invited to join NASP if they are not active NASP members.
Do not include my contact information in the NASP exchange.

WSPA sells members’ names, addresses, and emails for one time use when such requests are professionally appropriate for school psychologists.
Do not share my contact information with outside agencies.

History:

How many years have you been a WSPA member?

Voluntary
Contributions:

WSPA Minority Scholarship Fund: $
WSPA Childrens' Services Projects: $
Total: $

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