Name:_______________________________________________________
Mailing Address:_____________________________________________
________________________________________
zip__________________
Phone: (H)______________________ (W)__________________________
Fax:______________________ e-mail:_____________________________
Employer:_____________________________________________________
Current Position:_______________________________________________
KAPS Region: ________________________________________________
Please check any other association
memberships:
NASP____ KASA_____ KPA_____
APA_____ Other_____
Membership Type: Renewal____ New member____ Student____
Membership Dues: (please circle
amount)
Regular member $40.00
Student Member $10.00
Retired member $10.00
Associate Member $20.00
Membership Definitions:
Regular Member- Actively working as a school psychologist
Student Member- Undergraduate, graduate, or Interning student
Retired Member- Retired School Psychologist or related professional
Associate Member- Any professional interested in School Psychology
*Students--please provide
the following information:
Training Institution:_________________________
Advisor's Signature:________________________
Return form and dues
to: Courtney Bishop
825 Calypso Breeze Drive
Lexington, KY 40515