Membership Form
Name
*
Credentials
*
Membership Type
Professional
Associate
Student (Individual)
Student (Group Price)
Payment Method
Paypal
Check
Debit/Credit
Email
Phone Number
Work or Home Address
Region
Central
West Central
Southside
Hampton Roads
Eastern
Southwest
Northern
Valley
Type of Degree or Program
Bachelors of Music Therapy
Masters of Music Therapy
Doctorate of Music Therapy
Not Applicable
Other
School Attended
Graduation Date (if Applicable)
Population(s) served
Location of School or place of work (Name and Address)
Are you willing to have students shadow you?
Yes
No
Other
Do you own a Private Practice?
Yes
No
Are you interested in presenting at a business meeting?
Yes
No
If so, what topics are you interested on presenting on?
Is there an internship at your work site?
Yes
No
What topics do you want to see presented on at our VMTA business meetings?
Email
example@example.com
My Products
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( X )
Professional Membership
$
25.00
Associate Membership
$
35.00
Student Membership
$
15.00
University Rate (>50 Undergraduate Students)
$
75.00
University Rate (<50 Undergraduate Students)
$
50.00
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