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

Friends of Music Therapy Registration Form

Friend Name: ____________________________________________________________________

Organization: ___________________________________________________________________

Address: ______________________________________________________________________

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

Country: ______________________ Foreign Zip: _____ Email: ___________________________

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

Donor Name: ___________________________________________________   same as above

Address: ______________________________________________________________________

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

Country: ______________________ Foreign Zip: _____ Email: ___________________________

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

Group registration

Number of Friends

______

I authorize payment of $25, $50, Other $ ____________:        VISA        MasterCard        Check

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

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

 (The subscription year begins January 1 and ends December 31.
Those joining after January 1 will receive all previous materials sent up to that point.)

I am a:		Consumer	Policy maker	Educator	Family member	Musician
		Other: _________________________________

Applications are now being accepted for the January through December 2007 membership year. However, you may still join for the 2006 membership year and receive all the journals and publications mailed in this year if you wish. If you wish to join for this membership year, please make note of this on your application.