Clone of 2025 Membership Application Form Check Payment

Association for Indiana Music Therapy, Inc Membership Form

AIMT is a 501(c)3 nonprofit organization
I am a(n)*
Name*

First NameLast Name Credentials
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number*
School (students only)
Place of Employment
Website/Social Media for Employment
Job Title
Population(s) Served
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Number
I grant permission for AIMT to publish my contact information in the membership directory in the Members Only section of the AIMT website. Select all of the boxes below that you give permission to publish.*

NoNameEmailPhone NumberPlace of EmploymentJob TitleWork AddressWork NumberWebsite/Social Media
I would like for my information to be included in the "Contact a Speaker" section of the AIMT website. This is a list of professional MT-BCs available for speaking engagements at facilities and conferences. Your name and contact information would be posted on the "Contact Us" page of the AIMT website.*

YesNo
Topics I would be willing to present for the "Contact a Speaker"
Please recommend topics and ideas for future state conferences (include specific presenter/information):
Would you be interested in presenting at an AIMT state conferences? If so, please list topics.
Would you like AIMT to consider virtual conferences and events?*

Yes - this is helpful to me because I might attend virtuallyYes - this is helpful to others who may want to attend virtuallyNo - this is not necessary
What can AIMT do to better support music therapy in Indiana?
AIMT is always in need of volunteers to serve our purpose. Please check any areas below which you would be willing to assist.

Government Relations/AdvocacyAIMT OfficerPublic RelationsContinuing Ed/ProgrammingMentoring/Professional SupervisionOther
Coupon Code

Cyber Monday Deal! Expires December 1, 2025 at 12:00 ET 25% off Membership with Code "CyberMonday25" Check Must Be Postmarked and Dated for December 1, 2025 Early Bird Rate expires January 15, 2026: Use "2026EarlyBird" to receive $5 off your AIMT Membership! Check Must Be Postmarked and Dated by December 31, 2025
Membership Types and Cost

Professional Membership $25; Associate $20; Affiliate $30; Retired $10; Student $8 If you would like to Donate to the AIMT Intern Scholarship Fund feel free to include that amount on your check with the membership payment.
Please Indicate the number and type of Memberships you are purchasing here. If you are just registering your information in the form please feel free to skip this section.
If you plan to donate to the AIMT Scholarship Please Enter How Much You Are Donating Here.
By choosing to mail a check, I agree to send my payment in a timely manner, and understand that my membership is not active until my check is received by AIMT. If I fail to submit payment before end of the discount period, I understand that I am no longer eligible to receive the discount during the current membership year. Please send check and a copy of this form to: Association for Indiana Music Therapy C/O Mark Richins MM, MT-BC, 2506 Summerfield Dr, Lafayette, IN, 47909 Please Print the From to mail & Click "Submit Form"
Should be Empty:

Association for Indiana Music Therapy, Inc Membership Form

Coupon Code

Membership Types and Cost