Member Application (Combined) | Association of Pediatric Oncology Social Workers

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Use this form for new membership applications only.
* Note: All fields with an asterisk in their label are required fields.

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Your User Information

Username*

Password*

Enter Password Confirm Password

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NOTE: Your password must be at least 10 characters in length and contain at least one number and one upper case character.

Email*

Your Member Profile Information

Name*

First Last

Primary Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Add an Alternate/Home Address

I would like to add an alternate/home address

Alternate/Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credentials

Company/Institution

Phone - Work*

Phone - Personal

Area of Specialization

I would like to become more involved in APOSW

I want to become more involved in APOSW

My Interests

Joining an ongoing committee or Board of Directors
Becoming an abstract, social worker of the year or scholarship application reviewer
Writing for the newsletter or website
Helping at the annual conference as a SIG facilitator and/or session monitor

Display in the Member Directory

Yes

Membership Information

Have Discount

Do you have an Institutional Discount?

If so, check the box below to continue.

NOTE: Discounts can be applied only to a Regular - Member membership.

Do you have an Institutional Discount?

Institutional Discount*

Enter your Institutional Discount code above and click the Apply button.

Membership Type*

Membership Notes

Associate Member: Associate memberships are open to all non-social worker professionals who share in the APOSW mission.

Student: Students must supply proof of status at time of application. Send email to membership@aposw.org

Membership Transferability: APOSW memberships are non-transferable and valid from the submission date of this form through December 31st of the current calendar year. APOSW Membership must be renewed annually to receive uninterrupted member benefits.

Membership Type Institutional

Member - Regular

Payment Information

Total Dues Amount

$0.00

Payment Method

Credit Card
Check

Please Note: If you pay by check, your membership will be activated when the check has been received and deposited.

Make check payable to: Association of Pediatric Oncology Social Workers

Mail payment to:
Mary Laliberte, APOSW Treasurer
C/O Connecticut Children's Medical Center
282 Washington St, Suite 5A
Hartford, CT 06106

Credit Card*

Phone

This field is for validation purposes and should be left unchanged.

Membership Application Form

Your User Information

Your Member Profile Information

Membership Information

Payment Information

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