INSTRUCTIONS: 1.  If you wish to submit membership application and payment by check through the US Postal Service click here. 2.  To submit your membership application online and submit your dues via PayPal, please complete the membership form below, click the 'Submit" button at the bottom, and follow the instructions for PayPal. MEMBERSHIP APPLICATION FORM Please indicate the Membership Type that you are applying for: Professional Member $30.00 NCBRTL credentials will be verified upon receipt of application. Provisional/Professional Member $20.00 Include verification of graduation year Student Member $10.00 Anticipated date of graduation Para-Professional Member $25.00 NCBRTL credentials will be verified upon receipt of application. Supporting Member $20.00   Lifetime Member $360.00   Organizational Member $75.00     Last Name First Name and Middle Initial (If RT licensed, must match the name on your license) Employment Title or Position (abbreviate if necessary) Employer/Organization/School (abbreviate if necessary) Preferred Address Work Home School City State Zip     If Student, Permanent Address City State Zip   Phone Home Office School Fax Email     Indicate your preference for receiving the newsletter: US Mail or email (If email, please be sure to include email address in previous item) Check here if you do not wish to be included in the Membership Directory or e-groups (Directory will be on-line for members) .   My NCRTA Sponsor Is: (optional) HELP NCRTA RECRUIT RECREATIONAL THERAPY PROFESSIONALS NCRTA will annually award one-year free membership to its member who sponsors the most new members during that calendar year.   MEMBERSHIP STATISTICAL INFORMATION Data requested on this form will be used by NCRTA for program planning and evaluation. Data are for statistical purposes only. All personal information will be held confidential. You are not required to complete this section.     MAJOR CLINICAL SERVICE AREA HIGHEST LEVEL OF EDUCATION COMPLETED (Check one) (Check one) 1. Psychiatric/Mental Health 1. High School Diploma 2. Physical Medicine/Rehabilitation 2. Associate Degree in Recreational Therapy 3. Pediatrics 3. Associate Degree in other field 4. General Medicine 4. Baccalaureate Degree in Recreational Therapy 5. Substance Abuse 5. Baccalaureate Degree in other field 6. Gerontology 6. Masters Degree in Recreational Therapy 7. MR/Developmental Disability 7. Masters Degree in other field 8. Corrections 8. Doctoral Degree/emphasis in Recreational Therapy 9. Community 9. Doctoral Degree/emphasis in other field 10 OTHER 10 OTHER     RACE/ETHNIC GROUP TYPE OF POSITION (Check one) (Check one) 1. Native American 1. Therapist/Specialist 2. Hispanic/Latino 2. Supervisor 3. Asian American 3. Administrator 4. Pacific Islander 4. Instructor/Professor 5. African American/Black 5. Consultant 6. White/European American 6. Assistant 7. I refuse to give this information 7. Aide   8. OTHER     FIELD/PLACE OF EMPLOYMENT PRESENT SALARY RANGE (Check one) (Check one) 1. Hospital 1. $9,999 or less 2. Community (i.e. Day Program, PartialProgram, Physical Rehab, Out-patient, Mental Health) 2. $10,000 to $14,999 3. $15,000 to $19,999 3. Extended Care Facility/Assisted Living 4. $20,000 to $24,999 4. School System 5. $25,000 to $29,999 5. University & College 6. $30,000 to $34,999 6. Residential 7. $35,000 to $39,999 7. OTHER 8. $40,000 to $44,999   9. $45,000 to $49,999 AREAS OF INTEREST 10. Above $50,000 (Check all that apply)   1. Psychiatric/Mental Health MARITAL STATUS 2. Physical Medicine/Rehabilitation (Check one) 3. Pediatrics 1. Single 4. General Medicine 2. Married 5. Substance Abuse 3. Divorced/Separated 6. Gerontology 4. Widowed 7. MR/Developmental Disability   8. Corrections       YEARS OF EXPERIENCE IN RT YEAR OF BIRTH (Check one) 1. 0-2 years   2. 3-5 years SEX 3. 6-10 years Male Female 4. 11-15 years   5. Over 16 years       EMPLOYMENT STATUS   (Check one)   Employed in Recreational Therapy   1. Full time   2. Part time   Employed in field other than RT   3. Full time   4. Part time   Unemployed   5. Looking for work   6. Not looking for work   7. Retired   8. Student   9. Unemployed other (explain):