Wisconsin School Psychologists Association, Inc.

New Member Application Form
Membership for September 15^th, 2010-September 14^th, 2011

First Name:

Last Name:

My name has changed

Address:

This is a new address

City:

State:

ZIP:

Employer:

Home Phone:

Email Address:

Work Phone:

How many years have you been a WSPA member?

WSPA Region:

Don't know your region? Click Here

Check all that apply: I am a Nationally Certified School Psychologist.
I hold a WI School Psychologist Private Practice License.
I hold a Professional Psychologist Licensure.
I hold a DPI School Psychologist License.

*	Membership Category:

Contributions:

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

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.
I DO NOT want my information released to NASP.

WSPA sells members’ names, addresses, and emails for one time use when such requests are professionally appropriate for school psychologists.
I DO NOT want my information released.

WSPA needs your help! Volunteer for WSPA Committees.

Please check the committees you would be interested in:

Legislative Affairs
Membership
Nominations & Elections
Professional Training
Ethics Standards & Practices
Conference Planning
Newsletter

Long Range Planning
Children's Services
Public Relations
Continuing Professional Development
Recognition & Scholarship
Technology

Password:

Verify Password:

*	Password hint: