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Membership Type *	1st Year Regular Member for 2010-2011 ($85.00 for period up to 09/30/2011) 1st Year Regular Member for 2010-2011 Associate Membership for 2010-2011 ($100.00 for period up to 09/30/2011) Associate Membership for 2010-2011 Intern Membership for 2010-2011 ($40.00 for period up to 09/30/2011) Intern Membership for 2010-2011 Regular Membership (1 Year) for 2010-2011 ($125.00 for period up to 09/30/2011) Regular Membership (1 Year) for 2010-2011 Regular Membership (2 Years) for 2010-2012 ($230.00 for period up to 09/30/2012) Regular Membership (2 Years) for 2010-2012 Retired Membership for 2010-2011 ($60.00 for period up to 09/30/2011) Retired Membership for 2010-2011 Student Membership for 2010-2011 ($40.00 for period up to 09/30/2011) Student Membership for 2010-2011
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 '_'
Choose a Password * Must be 4 or more characters
Confirm your password * Enter password again
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?
Would you like to be assigned a mentor? *	Yes No
Would you like to be a mentor? *	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 of Advisor for verification purposes. University/Adisor's Name:
Intern Member Supervisor's Name University/Supervisor's Name:
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)	2010 2011 2012 2013 2014
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?
Do you possess the Bilingual Special Education Approval?	Yes No
If Yes, list languages
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
Are you:	Bilingual Multilingual
Language(s):
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
If you are employed in a school system, how is your salary determined?
If other determination, specify
If you are on a teachers� contract what is your lane placement?	MA+15 MA+30 MA+32 MA+45 MA+48 MA+54 MA+60 Other
If other lane placement, specify
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
Join ISPA Committee? *	Yes No
Please indicate if you would be interested in joining or learning more about the following ISPA committees: