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 Name
Last Name
Phone Number:
*
Site/Org Email:
*
example@example.com
Site/Org Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Voting Representative
(Each organization is allowed one vote per membership - please indicate your chosen voting member here.)
Voting Representative:
*
First Name
Last 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.)
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 Type:
*
Please Select
Academic (Graduate School) 100+ ($500)
Academic (Graduate School) 99 ($250)
Clinical Training Program ($100)
Individual Member ($50)
Select your membership option.
How would you like to pay for your membership?
*
Online (credit/debit)
Check
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Academic (Graduate School) 100+
A training program with 100 or more students applying for practicum each year.
$
500.00
Academic (Graduate School) 99
A training program with less than 100 students applying for practicum each year.
$
250.00
Clinical Training Program
A practicum site.
$
100.00
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.)
$
50.00
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