Please print out this form and mail or fax it to:
American Music Therapy Association • 8455 Colesville Rd, Ste. 1000 • Silver Spring, MD 20910 USA
Fax: (301) 589-5175 • Phone: (301) 589-3300

2009 AMTA Membership Registration

Name: ____________________________________________________Credentials: __________

Organization: ___________________________________________________________________

Address: ______________________________________________________________________

City: _____________________________________ State/Prov.: ________ Zip Code: _________

Country: ______________________ Foreign Zip: _____ Email: __________________________

Home phone: (______) ___________________ Work phone: (______) ____________________

I authorize payment for the designated amount:          VISA        MasterCard        Check

VISA/MC#: _________________________________________ Expiration date: _______/_______

Signature: ___________________________ Date: _________ Daytime Phone: (____)__________

 (The membership year begins January 1 and ends December 31. Members joining after January 1 will receive all publications sent up to that point in the membership year with their membership packet.)

Membership Category:

$220.00 - Professional				$220.00 - Associate
$80.00 - Student (see * below)				$80.00 - Graduate Student (see * below)
$125.00 - Retired				$650.00 - Patron (Businesses)
$1200.00 - Crescendo Patron				$2500.00 - Virtuoso Patron
$350.00 - Affiliate     (Schools & Institutions)				$350.00 - Educational Affiliate     (Schools offering music therapy degree programs)

Payment must be included for membership to be processed. Check/money orders payments must be mailed to AMTA.

   I am renewing my membership                      I am a new AMTA member

*If joining as a student member, please provide proof of student status below or copy of current student ID:

School or Clinical Training Site: ___________________________________________

Advisor's Signature: ____________________________________________________

Applications are now being accepted for the January - December 2009 membership year. However, you may still join for the 2008 membership year and receive all the journals and publications mailed in this year if you wish. If you wish to do so, please make note of this on your application.

   Occasionally, we make our members' addresses available to companies for mailings advertising products, services and educational opportunities which are relevant to the music therapy profession. If you would NOT like to be included in these mailings, please check this box.