Membership Registration | Illinois Activity Professionals Association

Name

First Last

Title/Position

Personal Information

Home Address

Street Address Address Line 2 City State ZIP Code

Phone

Fax

Primary Email*

Enter Email Confirm Email

Work Information

Facility Name

Work Address

Street Address Address Line 2 City State ZIP Code

Work Phone

Work Fax

Secondary Email

Enter Email Confirm Email

YOU MUST PROVIDE A VALID EMAIL ADDRESS FOR DELIVERY OF THE NEWSLETTER AND CONFERENCE INFORMATION

WE RECOMMEND YOU PROVIDE BOTH HOME AND WORK EMAIL IN THE EVENT YOU CHANGE EMPLOYMENT

IAPA WILL NEVER SELL OR DISTRIBUTE YOUR EMAIL ADDRESS

Certification

NCCAP
NAAPCC
IAPA
NCTRC
Other

Certification: Other

Please list

Association Affiliation

ICLTC
LSN
IHCA
NAAP
IPC
Local Association

Local Association

Please list

Type of Facility

Type of Facility: Other

Please list

Type of Residents/Clients

Geriatric
Mentally Ill
Developmentally Disabled
Alzheimer's
Other

Type of Residents/Clients: Other

Please list

Membership Type*

Facility Membership Description: The facility membership stays with the facility, not the individual applying for membership; everyone in the facility qualifies for membership rates for the annual conference and other educational opportunities; everyone in the facility is eligible for awards; eligible applicants in the facility can apply for certification

Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name