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Membership Application & Questionnaire
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Date:
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mm/dd/yy
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Name:
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Degree:
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Profession:
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Agency (If applicable)
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Home or Work Street Address:
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City:
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State:
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Zip Code:
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Work County:
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Work Phone:
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Work Fax:
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Email Address:
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Do you want your information to appear on our website please:
YES
NO
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Please select member categories: (UAIMH, WAIMH or Both)
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UAIMH
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WAIMH
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Regular
Regular with Journal
Student**
Student with Journal
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$10
N.A
$10
N.A
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$70
$115
$40
$85
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Are you a member of WAIMH?
Yes
No
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If yes would you like to submit your dues through us?**
Yes
No
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UAIMH
dues
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WAIMH
dues
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Total dues
submitted
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Totals:
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$
+
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$
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=
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Please fill out UAIMH and WAIMH totals. If not applying for WAIMH membership please put 0 in the WAIMH box. |
Please choose your main areas of interest:
(circle no more than 5)
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01
Adolescent pregnancy
02
Adoption Issues
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Affective Development
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Anxiety/Inhibition
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Attachment Theory and issues
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Autism
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Child Abuse
08
Child with chronic illness
09
Childhood Psychosis
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Cognitive Development
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Cross-Cultural Studies
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Depression
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Developmental and behavior pediatrics
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Developmental Psychopathology
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Divorce and remarriage
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Early Childhood programs
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Failure to thrive
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Family processes
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Fathers
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Feeding disorders
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Foster care
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Infants - disabled, special needs, and developmental delays
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Infants - at risk medically, socially, etc.
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Infant and toddler day care
25
Infants with mentally ill mothers
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Infant mental health services
27
Infant - parent interaction
28
Infant observations and experimental research
29
Infant/Mother/Therapist interaction
30
Mental retardation and learning disabilities
31
Normal and abnormal preschool development
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Nutrition
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Pediatric care
34
Pediatric physiotherapy
35
Prenatal loss
36
Pregnancy and prenatal period
37
Prenatal development
38
Prevention and early intervention
39
Professional development, treatment issues, supervision
40
Public policy
41
Sex role development, sex differences
42
Sibling relationships
43
Sleep disorders
44
Socialization and discipline
45
Temperament
46
Transitions to parenthood
47
Triadic interventions
48
Violence
49
War children
50 Other
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*** Members of the WAIMH can earn money for the affiliate (UAIMH ). An amendment
adopted by the board of directors allows for $7.50 to go to UAIMH
Would you like this amount to be rebated to UAIMH?
YES
NO
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