DSPP Registration

REGISTRATION FOR DSPP MEMBERSHIP and WORKSHOP

2005-2006

NAME: ____________________________ TELEPHONE: (O) _____________ (H) _____________

MAILING     ________________________
ADDRESS: ________________________
                  ________________________ FAX: _____________ E-MAIL: ___________________

HIGHEST DEGREE: ________ YEAR: ____________

SCHOOL: __________________________ LICENSED/CERTIFIED AS: ____________________

PROGRAM: ________________________ MEMBERSHIP: ____Full ____Associate ____Student

SPECIALTIES IN PRACTICE ____________________________________________________________

Do you want the above information to be listed in the DSPP Directory?              ____Yes ____ No
Do you want the above information to be listed on the DSPP Web Site?              ____Yes ____ No
(Note: payment of dues must be made by September 22nd to be listed in the print Directory)
PLEASE INDICATE DSPP COMMITTEE INTEREST:

PROGRAM ______

ARTS ______

EDUCATION ______ APA MEMBER?              ___Yes ___No

MEMBERSHIP ______

COMMUNITY RELATIONS ______
DIVISION 39 MEMBER? ___Yes ___No

CONTINUING EDUCATION ______

DSPP BULLETIN ______

Instructions:
Circle each applicable fee in the column corresponding to your level of membership
Take 10% discount if mailing on or before September 08, 2004; indicate total on bottom line
Return this page with your check payable to DSPP to:
Alexa Marrach, Ph.D. , DSPP Membership Chair
8350 Meadow Road Suite 272
Dallas, Texas 75231


Full Member

Associate Member

Student Member**

Non-member

Yearly Dues

80.00

50.00

30.00

N/A

Program Readings

20.00

20.00

20.00

20.00

Spring Workshop April 22, 2006 *

100.00

80.00

35.00

120.00

Susan Roos, PhD           "Chronic Sorrow: Dream and Reality"

Subtotal

______

______

______

______

Minus 10% discount if mailing prior to September 03, 2004

______

______

______

______

Tax Deductible Donation to DSPP Arts
______

______

______

______

Total enclosed

______

______

______

______

* Lunch included with workshop fees
** Student membership dues may be waived in lieu of volunteer work on a DSPP committe; however, students
are still requested to complete a registration form.
*** please include a separate check with memo line completed 'dspp arts'

.

REGISTRATION FOR DSPP MEMBERSHIP and WORKSHOP 2005-2006
NAME: ____________________________	TELEPHONE: (O) _____________ (H) _____________
MAILING ________________________ ADDRESS: ________________________ ________________________	FAX: _____________ E-MAIL: ___________________
	HIGHEST DEGREE: ________ YEAR: ____________
SCHOOL: __________________________	LICENSED/CERTIFIED AS: ____________________
PROGRAM: ________________________	MEMBERSHIP: ____Full ____Associate ____Student
SPECIALTIES IN PRACTICE ____________________________________________________________

PROGRAM	______
ARTS	______
EDUCATION	______	APA MEMBER? ___Yes ___No
MEMBERSHIP	______
COMMUNITY RELATIONS	______	DIVISION 39 MEMBER? ___Yes ___No
CONTINUING EDUCATION	______
*DSPP BULLETIN*	______

	Full Member	Associate Member	Student Member**	Non-member
Yearly Dues	80.00	50.00	30.00	N/A
Program Readings	20.00	20.00	20.00	20.00
Spring Workshop April 22, 2006 *	100.00	80.00	35.00	120.00
Susan Roos, PhD	"Chronic Sorrow: Dream and Reality"
Subtotal	______	______	______	______
Minus 10% discount if mailing prior to September 03, 2004	______	______	______	______
Tax Deductible Donation to DSPP Arts	______	______	______	______
Total enclosed	______	______	______	______