Membership Registration Form Phone Email Address * Last Name * First Name * Credential(s) Choose One MT-BC RMT CMT ACMT Other Address (Line 1-Street) Address (Line 2-Street) Town/City State Choose One NJ PA NY Other Zip Code County Choose One I am not a New Jersey resident Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Phone Number (Preferred) Phone Number (Work) Type of Membership Choose One Active - $25 ($20 if received by 1/31/18) Couples - $35 (30 if received by 1/31/18) Student - $5 Retired - $10 Associate/Friend of Music Therapy - $15 Affiliate Organization - $30 Student Members - School where you are studying music therapy Student Members - Are you a(n) undergraduate, graduate, or doctoral level student? Choose One Undergraduate Graduate Doctoral Student Members - Anticipated graduation date Choose One 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 Name of Primary Workplace/Business/Private Practice (or write: Student/Associate Member) Workplace Address (Line 1) Workplace Address (Line 2) Workplace (Town/City) Workplace (State) Workplace (Zip Code) Setting(s) Served (Check all that apply) * Currently a Student or Associate member Adult Day Care Adult Education Child/Adolescent Treatment Center Children's Day Care/Preschool Children's Hospital or Unit Community Based Service Community Mental Health Center Correctional Facility Day Care/Treatment Center Drug/Alcohol Program Early Intervention Program Forensic Facility General Hospital Geriatric Facility - Not Nursing Geriatric Psychiatric Unit Group Home Home Health Agency Hospice/Bereavement Services Intermediate Care Facility (ICF/DD) Inpatient Psychiatric Unit Labor/Delivery Military Base Music Retailer Music Therapy Business Owner Oncology Outpatient Clinic Partial Hospitalization Physical Rehabilitation Private Music Therapy Agency School (K-12) Self-Employed/Private Practice State Institution Support Groups University/College Veteran's Affairs Wellness Program/Center Other Population(s) served (please check all that apply) * Currently a Student or Associate member Abused/Sexually Abused AIDS Alzheimer's/Dementia Autism Spectrum Behavioral Disorder Bereavement/Grief Cancer Chronic Pain Comatose Developmentally Disabled Dual Diagnosed (Mentally Ill/Chemically Addicted) Dual Diagnosed (IDD/Mentally Ill) Early Childhood Eating Disordered Elderly Persons Emotionally Disturbed Forensic Head Injured Hearing Impaired Hospice/Palliative Care Labor/Delivery Learning Disabled Medical Surgical Mental Health Multiply Disabled Music Therapy College Students Music Education College Students Neurologically Impaired Non-disabled Parkinsons Physically Disabled Post Traumatic Stress Disorder Rett Syndrome School Age Population Speech Impaired Stroke Substance Abuse Terminally Ill Visually Impaired Other Primary age groups served Infants (0 to 3 years) Children (4 to 12 years) Adolescents/Young Adults (13 to 25 years) Adults (26 to 65 years) Older Adults (66+ years) Are you accepting private practice referrals? Choose One Yes No Other For those accepting private clients - Counties where you primarily provide services (please check all that apply) Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Legislative DistrictFind your district information here Choose your legislative district Choose One I am not a New Jersey Resident 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Legislative District of your primary work address Choose One I work out of state/I am a student 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 How can NJAMT best support you? Choose One Continuing education opportunities Private practice referrals Mentorship (for music therapists who are within two years of having graduated) Information about employment opportunities Information about licensure/government relations Other: I am interested in supporting NJAMT in the following ways: Short-term projects Music therapy advocacy days Serving on a committee Public relations speaker Hosting workshops Hosting an NJAMT gathering Helping with social media Other Please tell us how you prefer to receive information about NJAMT news, continuing education opportunities, events, employment information, social gatherings, etc. NJAMT Facebook page NJAMT Twitter account NJAMT Yahoo group Message to your preferred email address Phone calls/text to your preferred phone number Snail mail to your home address Please don't send me any information Other Other method of communication Please list any other professional organizations to which you belong:
