ACLP Child Life Program Membership Roster Update Form

ACLP Child Life Program Roster Update Form
Submitter's Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
ACLP Number
Child Life Program Information
Child Life Program Name*
Facility Type*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (as to be shown in Child Life Program Directory)*
example@example.com
Phone Number*
Please enter a valid phone number.
Program Description*
Staff List

Complete this section to add your team to your membership. An invoice will be sent once your application is processed.
Please add your list of staff members to be included in your membership. You MUST include first name, last name, email address, job title, and individual member type for each staff. If known, please include the ACLP ID numbers as this will expedite the processing of your membership.
Please verify that you are human*
Should be Empty:

ACLP Child Life Program Roster Update Form