Membership of  ADPCA

Additional contributions are welcome from those who would like to provide membership or meeting costs for other less able to pay the full amount. Please remember that money values are very different in many non-western countries.

You can use the form below to join, renew your membership or leave the Association.

2007 Association for the Development of the Person Centered Approach Membership Form

Words in blue are for those who use International or British English.

Please indicate: Mr., Ms., Mrs., Dr. or other                              Date:

Please print or type

Name;________________________________________________________________________

E-Mail Address:________________________________________________________________

Cell/Mobil phone:(include country code if not the USA) ________________________________

Day time phone:________________________________________________________________

Night phone:___________________________________________________________________

Mailing/Postal address:__________________________________________________________

______________________________________________________________________________

Do you do client-centered psychotherapy?  Yes________   No___________

Do you describe yourself as a person-centred/client-centred counsellor/psychotherapist?

Yes _________ No _________

If you would prefer not to have the information above listed in the membership directory, please circle that which you don’t want listed: mailing/postal address, cell/mobile phone #/number, night phone #/evening phone number, day time phone #/number, or e-mail address.

______If you no longer wish to be a member, please mark X and return this form to me. If you can give me a notion of why you no longer wish to be a member, I would appreciate it. Thanks.

_________ 1 year regular/standard membership dues/fee now until May 31, 2008/31 May 2008 ( Journal & bi-annual Renaissance) $65.00

Topic of interest or research______________________________________________________________________

______5 year membership until May 31, 2013/31 May 2013 (yearly Journal and bi-annual Renaissance)$250

_________1 year student membership until May 31, 2008/31 May 2008 (Journal & bi-annual Renaissance) $25.00              

Name of School/Educational Establishment __________________________________________

                              Expected year of graduation/completion_______________

______ I would like to renew my membership with ADPCA and receive both on-line Renaissance and the yearly Journal but am not able to pay the full amount.  I have enclosed a check for ____________ or have sent __________ through Paypal.

-----------I request a full scholarship/bursary and receive both on-line Renaissance and the yearly Journal.

The Journal will continue to be printed and will be mailed out/posted. The Renaissance, the newsletter, will go out/be dispatched by e-mail to members.

 Please print (or e-mail to paulrblanchard@earthlink.net) this form and send it to:
ADPCA, PO Box 1427, Westford, MA. 01886-4927. United States of America.

If you have access to an US$ bank account please write a check to ADPCA and including it. Those who do not have access to a US$ bank account can send a traveler's check/traveller's cheque made payable to "ADPCA" and crossed "not negotiable". Traveler's checks/Traveller's Cheques must be drawn in US$.

My phone # / number is shown above. Remember to take time differences into account. MA is 5 hours behind Universal Time.

If you would like to pay by Credit Card please answer the following questions:
 

Card #/number.............................................................................................................

Expiry date (MM/YY).................................................................................................

Signature......................................................................................................................

Please mail/post (address above)