ISPA

Membership Renewal/Application Form

Personal Information

Form Type
What is your preferred mailing address?
First Name
Last Name
Home Address
Home City
Home State
Home Zip Code
Home Phone (eg. 123 456 7891)
Fax (eg. 123 456 7891)
Email
Employer or University
Work Address
Work City
Work State
Work Zip Code
Work Phone (eg. 123 456 7891)

Membership Status: (Please read below for details)

Regular:

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. Regular members may apply for leave-of-absence status if appropriate. Please contact the Membership Committee for information.

Certification Number(For New Members Only):

Retired:

Open to anyone holding Regular membership for a period of five consecutive years and who retires from remunerative professional activity.

Associate Members:

Members in this category may not vote or hold office, but have an interest in the field of school psychology.

Student:

Open to those enrolled half-time or more (minimum six semester hours or equivalent per semester) in a program leading to an advanced degree or 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. Please include name of Advisor for verification purposes.

First Name

Last Name

Intern:

Open to those enrolled half-time or more (minimum six semester hours or equivalent per semester) in a program leading to an advanced degree or 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. Must include name of university and Advisor's signature on renewal form.

First Name

Last Name

Optional Information

Education Level. What is your highest degree earned?

To better serve your continuing education needs, please list all your credentials, certifications, and licenses.

Demographic Information

Primary Position (Choose one):

If you chose "Other" in the above option, please specify

In what Special Education Cooperative is your employment located?

Do you possess the Bilingual Special Education Approval?

If yes, please specify language(s)?

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 during the membership renewal year?

Yes No

Based on our accounting, the Illinois School Psychologists Association estimates that 11% 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.

Payment Options:
Payment in full (payable to ISPA)
Credit Card	Mail in Payment Mail to : ISPA P.O. Box 847 Bloomingdale, IL 60108-0847

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