Join Now

THE SOCIETY OF PEDIATRIC PSYCHOLOGY
DIVISION 54, AMERICAN PSYCHOLOGICAL ASSOCIATION

MEMBERSHIP APPLICATION FORM

Please print and return this form with payment to:
APA Division54
c/o Karen Roberts
P.O. Box 3968
Lawrence, KS 66046

Please provide the following contact information:

DUES
$45	Member of American Psychological Association Membership No.
$45	Psychologist but not member of American Psychological Association
$45	Physician
$45	Allied professional at or below doctoral level
$20	Actively enrolled psychology student (undergraduate, graduate, post doctoral training) * Faculty Advisors Signature __________________________
$30	Fully retired
Enter Dues Paid
BILLING
Credit Card
Cardholder Name
Card Number
Expiration Date	Signature _____________________________