Membership Application & Questionnaire

Date: mm/dd/yy
Name:
Degree:
Profession:
 
Agency (If applicable)
Home or Work Street Address:
City:
State:
Zip Code:
Work County:
 
Work Phone:
Work Fax:
Email Address:
 

Do you want your information to appear on our website please:
YES  NO

   
Please select member categories: (UAIMH, WAIMH or Both)
  UAIMH WAIMH

Regular
Regular with Journal
Student**
Student with Journal

$10
  N.A
$10
  N.A
$70
$115
$40
$85
Are you a member of WAIMH? Yes No
If yes would you like to submit your dues through us?**
Yes No
  UAIMH
dues
WAIMH
dues
Total dues
submitted
Totals: $ + $ =
                  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)

01 Adolescent pregnancy
02 Adoption Issues
03 Affective Development
04 Anxiety/Inhibition
05 Attachment Theory and issues
06 Autism
07 Child Abuse
08 Child with chronic illness
09 Childhood Psychosis
10 Cognitive Development
11 Cross-Cultural Studies
12 Depression
13 Developmental and behavior pediatrics
14 Developmental Psychopathology
15 Divorce and remarriage
16 Early Childhood programs
17 Failure to thrive
18 Family processes
19 Fathers
20 Feeding disorders
21 Foster care
22 Infants - disabled, special needs, and developmental delays
23 Infants - at risk medically, socially, etc.
24 Infant and toddler day care
25 Infants with mentally ill mothers
26 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
32 Nutrition
33 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

   

*** 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