Sign-up



Membership Type *






Payment System *

Your Name *
Your First & Last name
Your E-Mail Address *

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 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? *

Would you like to be a mentor? *

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.
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

Contract Length (Days)
School Psychology Experience
Psychologist to Student Ratio
Year of Graduation (students)




Are you a member of: (check all that apply)





Other Professional Affliations
Are you a Nationally Certified School Psychologist (NCSP)?

If yes when is your NCSP renewal?
Do you possess the Bilingual Special Education Approval?

If Yes, list languages
Would you be willing to speak at an ISPA workshop or be listed in our Speakers' Bureau?

If so, list topic(s)
Your Age
Gender

Are you:

Language(s):
Race/Ethnicity:







If other race/ethnicity, 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?

Join ISPA Committee? *

Please indicate if you would be interested in joining or learning more about the following ISPA committees:
I prefer to print my membership card on the ISPA Website (available beginning October 1), as part of a paper product reduction effort. *

I prefer to access a digital copy of the School Psychology in Illinois Newsletter on the ISPA website, as part of a paper reduction effort.. *


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.




Powered by aMember Pro membership software


© CGI-Central.NET, 2002–2012