Professional (not AMTA member) Membership Form
Personal Information:
Name:
Address:
Address:
City, ST Zip:
E-mail:
Home Phone:
Employer/Business:
Company:
Address:
Address:
City, ST Zip:
Work Phone:
If private practice, check the box.
Populations Served:
Check all that apply:
Abused/Sexually Abused
AIDS
Alzheimer's/Dementia
Autism Spectrum Disorders
Behavior Disorder
Cancer
Chronic Pain
Comatose
Dev. Disabled
Dual Diagnosed
Early Childhood
Eating Disorders
Elderly Persons
Emotionally Disturbed
Forensic
Head Injured
Hearing Impaired
Learning Disabled
Medical/Surgical
Mental Health
Multiply Disabled
Music Ed. College Students
Mus. Therapy Coll. Students
Neurologically Impaired
Non-Disabled
Other
Parkinsons
Physically Disabled
Post Traumatic Stress Disorder
Rett Syndrome
School Age Population
Speech Impaired
Stroke
Substance Abuse
Terminally Ill
Visually Impaired
Preferences:
Yes, print my contact information in the MTAG Directory.
(Directory is distributed to members only.)
Yes, I would like to receive correspondence via e-mail.
Participation:
I am interested in helping with the following committee(s):
Job Development
Government Relations
Reimbursement
Communications
Scholarship
Dues:
$20
Professional Membership
$20
Friends of MTAG (required for non AMTA members)
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$40
Total