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Membership Type *	1. Regular Membership (1 Year) for 2012-2013 ($125.00 for period up to 09/30/2013) Members in this category must hold a Type 73 certificate in School psychology or its equivalent if from out of state. University trainers of school psychologists, administrators, and others who do not meet this requirement may apply but are subject to review by the Governing Board. 2. Regular Membership (2 Years) for 2012-2014 ($230.00 for period up to 09/30/2014) Members in this category must hold a Type 73 certificate in School psychology or its equivalent if from out of state. University trainers of school psychologists, administrators, and others who do not meet this requirement may apply but are subject to review by the Governing Board. (8 % discount on the yearly rate for both years if you renew as a Regular member for two years). 3. 1st Year Regular Member for 2012-2013 ($85.00 for period up to 09/30/2013) May be used one time only for your first year as an ISPA Member in the Regular Member Category. Members in this category must hold a Type 73 Certificate in School psychology or its equivalent if from out of state. 4. Retired Membership for 2012-2013 ($60.00 for period up to 09/30/2013) Open to anyone holding Regular membership for a period of five consecutive years and who retires from remunerative professional activity. 5. Associate Membership for 2012-2013 ($100.00 for period up to 09/30/2013) Members in this category may not vote or hold office, but have an interest in the field of school psychology. 6. Intern Membership for 2012-2013 ($40.00 for period up to 09/30/2013) Open to those enrolled half-time or more (minimum six semester hours or equivalent per semester) in a program leading to a post-master’s certificate in school psychology. The student membership status may be granted for no more than five years (including the internship), requires annual verification, and is not granted to any person employed full-time. The university the intern attends, and the name and contact information of the Intern Supervisor is required (later in this form). 7. Student Membership for 2012-2013 ($40.00 for period up to 09/30/2013) Open to those enrolled half-time or more (minimum six semester hours or equivalent per semester) in a program leading to a post-master’s certificate in school psychology. The student membership status may be granted for no more than five years (including the internship), requires annual verification, and is not granted to any person employed full-time. The university the student attends, and the name and contact information of the University Advisor is required (later in this form).
Payment System *	PayFlow Link Credit Card Payment
Your Name * Your First & Last name
Your E-Mail Address * A confirmation email will be sent to you at this address
Choose a Login Name (User ID) * It must be 4 or more characters in length and may only contain small letters, numbers, and the underscore '_'
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Preferred Address	Home Work
Home Address *
Home City *
Home State *
Home Zip Code *
Home Phone *
Fax
University (for Students/Interns only)
Employer
Address
City
State
Zip Code
Work Phone
In what special education cooperative or school district is your employment located?
ISPA may make available at an appropriate charge, the full or partial lists of the members to certain carefully selected companies or organizations serving the fields of general and special education. Do you wish to have your name included on such lists? *	Yes No
Regular Member Certification Certification Number (For New Members Only):
First Year Member Certification Certification Number:
Student Member Advisor's Name Please include name, email address, and phone number of Advisor for verification purposes.
Intern Member Supervisor's Name Please include name, email address, and phone number of Supervisor for verification purposes.
I prefer to print a copy of my membership card on the ISPA web site. (Available after Nov 1, 2012). *	Yes No
I prefer to access a digital copy of SPII newsletter on the ISPA web site rather than receive a hard copy by mail. *	Yes No
I prefer to renew my membership online rather than receive a hard copy renewal application via mail in the future. (Email reminders will still be sent.) *	Yes No
Would you like to be assigned a mentor? *	Yes No
Would you like to be a mentor? *	Yes No
Highest Degree Earned?
If other degree, specify
Please add any additional credentials, certifications, or licenses.
Primary Position
Employment Setting (select up to 3)
If Other, please specify
Annual Salary
Full or Part Time	Full Time Part Time
Contract Length (Days)
School Psychology Experience
Psychologist to Student Ratio
Year of Graduation (students)	2012 2013 2014 2015 2016
Are you a member of: (check all that apply)	NASP (National Association of School Psychologists) CASP (Chicago Association of School Psychologists NISPA (Northern Illinois School Psychologist Association) SISPA (Southern Illinois School Psychologist Association) WSSP (Western Suburbs School Psychologists) Other professional affiliations
Other Professional Affliations
Are you a Nationally Certified School Psychologist (NCSP)?	Yes No
If yes when is your NCSP renewal?
Are you:	Bilingual Multilingual
Language(s):
Do you possess the ISBE Bilingual Special Education Approval as a Bilingual School Psychologist?	Yes No
If Yes, in what language(s)
By answering "yes" to this question, I agree to give ISPA permission to publish my name and email address as a Bilingual School Psychologist in electronic format on its website. By selecting either yes or no and entering today’s date, I verify that the information on this item is true, complete, and accurate.	Yes No
ISBE Agree Date
Would you be willing to speak at an ISPA workshop or be listed in our Speakers' Bureau?	Yes No
If so, list topic(s)
Your Age
Gender	Male Female
Race/Ethnicity:	Hispanic (Mexican-American, Puerto-Rican, etc.) White, not Hispanic African-American, Black Native-American, Indian Asian-American or Pacific Islander Bi-racial Prefer not to answer Other
If other race/ethnicity, specify
Join ISPA Committee? *	Yes No
Please indicate if you would be interested in joining or learning more about the following ISPA committees:

As a new member, you will be assigned a membership id number within 24 hours. This information will be made available in your member profile.

Your membership card may also be printed (or is also available) from your 'edit profile' menu.

Based on our accounting, the Illinois School Psychologists Association estimates that 6% of your dues are for lobbying expenses, which are non-deductible. Check with your accountant on the balance of your ISPA membership dues to determine their deductibility.