Membership Application

Individual Whole Group Membership

Prefix

First Name *

Middle Name

Last Name *

Suffix

Primary Email *

Alternate Email

Practice Group(s)

Primary Practice Group

Additional Practice Groups

Main Office Details

Address

Street Address *

City *

State/Province/Territory *

Country *

Postal code *

Sharing Preferences

Display in Public Directory *

Yes

Data Sharing *

Yes

IACP occasionally makes its members' addresses (excluding telephone and email) available to other colleague organizations and to vendors who provide products and services to the Collaborative community. If you prefer not to be included in these lists, please select 'no'.

Professional Information

Area(s) of Practice *

License(s) *

Website Link

Facebook Link

LinkedIn Link

Education Information

Please enter information in the following format: Name of Institution, 4-digit-year

Example: Loyola Marymount, 1991

Undergraduate Education

Postgraduate Education

Professional Education

Additional Details

Introduction / Very Brief Bio

Accommodations

Proficient in LGBT matters

Disabled-accessible office

Multilingual

ASL

Who Referred You to IACP?

Is there anything else that you need us to know about your application?

Sell Products *

Membership: Whole Group (One-Year)

$145