Membership Application Form Check Payment

Association for Indiana Music Therapy, Inc Membership Form

AIMT is a 501(c)3 nonprofit organization
Name*

First NameLast Name Credentials
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone Number*

Area CodePhone Number
Place of Employment
Job Title
Population(s) Served
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Number

Area CodePhone Number
I grant permission for AIMT to publish my contact information in the membership directory in the Members Only section of the AIMT website.*

YesNo
I would like for my information to be included in the Speaker’s Bureau. (Please list below any topics about which you are willing to present.)*

YesNo
Topics I would be willing to present for the Speaker's Bureau
Please recommend topics and ideas for future state meetings (include specific presenter/information):
Would you be interested in presenting at an AIMT state meeting? If so, please list topics.
What day/time/location works best for you to attend meeting and training opportunities?
What is the most valuable aspect of membership with AIMT for you?
What can AIMT do to better support music therapy in Indiana?
What other professional organizations are you involved in?
AIMT is always in need of volunteers to serve our purpose. Please check any areas below which you would be willing to assist.

Government Relations/AdvocacyWebsite ManagementAIMT OfficerHosting an AIMT meeting at your facilityPublic RelationsContinuing Ed/ProgrammingMentoring/Professional SupervisionOther
Method of Payment

Credit/debit card (Please enter card information below)I will mail a check
By choosing to mail a check, I agree to send my payment in a timely manner, and understand that my membership is not active until my check is received by AIMT. If I fail to submit payment before end of the discount period, I understand that I am no longer eligible to receive the discount during the current membership year.*

Agree
Please send check and a copy of this form to:

Association for Indiana Music Therapy, Inc
C/O Jennifer Whitlow, MT-BC
348 Entrance Hall View
Greenwood, IN 46142
I am a(n)*
Dues

Professionals: $25

Associate: $20

Affiliate: $30

Retired: $10

Student: $8
Please enter applicable payment amount below.
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Association for Indiana Music Therapy, Inc Membership Form