ACEPT Annual Membership Registration

Annual Membership Registration

Please complete the information below in order to renew your annual membership or register as a new member with ACEPT by the end of October.
Name of Site/Organization: *
(Please make sure to include Name of Organization in 'Memo' for Payment)
Director of Training:*

First NameLast Name
Phone Number:*
Site/Org Email:*
example@example.com
Site/Org Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Voting Representative

(Each organization is allowed one vote per membership - please indicate your chosen voting member here.)
Voting Representative:*

First NameLast Name
Voting Representative Email:*
example@example.com
ACEPT Guidelines Agreement
As an ACEPT member, my organization and I hereby support the missions of ACEPT and abide by the ACEPT guidelines.*

I agree.
If you have any questions about the guidelines and/or mission of ACEPT, please contact the ACEPT President at president@aceptchicago.org.
Membership Type

(Please indicate how you want to pay & your memership category.)
Membership Type:*
Select your membership option.
How would you like to pay for your membership?*

Online (credit/debit)Check
To pay via check (ONLY if company policy necessitates this payment type)

Mail check (with organization/member name indicated on memo line) payable to ACEPT to the ACEPT Treasurer: Greg Harms, Psy.D. 4203 N. Sheridan Rd. #3N Chicago, IL 60613. Please direct questions to treasurer@aceptchicago.org.

Membership Options*

Academic (Graduate School) 100+

A training program with 100 or more students applying for practicum each year.

$510

Academic (Graduate School) 99

A training program with less than 100 students applying for practicum each year.

$260

Clinical Training Program

A practicum site.

$110

Individual Member

A person who joins as an individual rather than as part of an academic program or training site. (NOTE: this category will not be able to participate in the Practicum Fair as an agency.)

$60

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

Annual Membership Registration

Voting Representative

ACEPT Guidelines Agreement

If you have any questions about the guidelines and/or mission of ACEPT, please contact the ACEPT President at president@aceptchicago.org.

Membership Type

To pay via check (ONLY if company policy necessitates this payment type)