IPAA 2010 Membership Application
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| Select a Membership Category |
| Membership Type: * |
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| Applicant Information |
| First Name: |
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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Cell Phone: |
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| Office Phone: |
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| Fax: |
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| E-mail: |
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| Website: |
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| School |
| Name: * |
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Regionally Accredited |
| Degree awarded/will be awarded on: * |
Please enter highest degree. |
| License |
| Type: |
registered interns may also enter information. |
| Lic#: |
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| Expires on: |
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| Permissions |
| Permission to publish name and address in Online Directory: * |
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| Permission to subscribe to IPAA listserv: * |
If YES, Please type your E-mail address that you would like to use for IPAA LISTSERV. |
| Referral Source |
| How did you hear about IPAA: * |
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| Other Information |
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PROFESSIONAL ETHICS DECLARATION
I hereby release and further agree to indemnify and hold harmless, the IPAA, its officers, board, committee members, individual members, and other affiliates (including but not limited to participants, employees, agents, volunteers, partners, sponsors, advertisers, subcontractor, and owners/lessors /lessees of premises on which the IPAA activities take place) from any and all losses, damages, injuries, and liability loss costs or obligations arising out of, or directly or indirectly relating to IPAA Activities/ Meetings/Programs/and other Events. Therefore, I undersigned, have read, understand, and hereby wholly agree to this Release of Liability and Indemnity and Hold Harmless Agreement.
I have also read and agree to abide by the Code of Ethics as indicated by the Code of Ethics of the California Psychological Association (Identical to Code of Ethics of the American Psychological Association).
If you agree with this statement and would like to become a member/renew please type "I agree" in the box on the left.
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