ATRS Membership Application

New Member

Renewal

Name:
Title:
Agency:
Address:
City:
State:
Zip:
Work Phone:
Home Phone:
Fax:
Email:
NCTRC Certification Number:

Membership Certification (Check One)

	Professional	($30.00)
	Associate	($15.00)
	Student	($10.00)
	Supporting	($15.00)
	Organizational	($75.00)

Optional Confidentiality Release:
I agree that ATRS may release my name, work address, home address, certification level and certification expiration date for individuals and/or organizations for educational and research purposes.

Applicant Signature: _______________________________________

Thank you for your interest in ATRS. Memberships are current from conference to conference since these are the times when most members join, so if you join at the spring conference, you will not renew until the next spring conference. Whether you are a new member or renewing your membership we appreciate you. Please fill out and make check payable to ATRS and send to:

Arkansas Therapeutic Recreation Society
Sherrie Shinn
Little Rock Parks and Recreation
500 West Markham RM 108
Little Rock, AR 72201
501-918-5215