PSCA Membership Application/Renewal Form

PSCA Membership Application

We're so happy to have you join PSCA! Please complete the form below. Questions? Please email info@paschoolcounselor.org.
Please note:

We will have application processing delays during the month of August as we transfer our membership data to our new database. Your patience is greatly appreciated!
I am:

A new memberCompleting my membership renewal
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Preferred Method of Contact

EmailPhone
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Mailing Address

HomeBusiness
School District*
Intermediate Unit Number*
There are 29 intermediate units in the Commonwealthof Pennsylvania, each serving a given region.
Professional Setting*

AdminProfessionalRetiredStudentAssociate
If you are currently a student, when is your anticipated graduation date?

MonthDayYear
Date
Professional Level*

Elementary SchoolMiddle SchoolHigh SchoolCounselor EducatorCounselor Supervisor
Which gender do you most identify with?

I do not wish to respondNonbinaryFemaleMaleOther
What are your pronouns?

I do not wish to respondThey/ThemShe/Her/HersHe/Him/HisOther
Counseling Certification or School ID *

Ex: Letter from district, picture of school ID, copy of certificate, transcript (student membership)
Cancelof
I am paying:

By CardBy CheckDistrict Group Dues (Check)

Membership

District Group Dues (Check)

$ Free

Paying By CheckPlease note: your membership will not be active until the check is received.

$ Free

Regular Member

$60.00

Professional Member

$60.00

Associate Status

$60.00

Student Membership

$30.00

Retired Membership

$30.00

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: