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THE SOCIETY OF PEDIATRIC PSYCHOLOGY
DIVISION 54, AMERICAN PSYCHOLOGICAL ASSOCIATION

MEMBERSHIP APPLICATION FORM

Please print and return this form with payment to:
Society of Pediatric Psychology
P.O. Box 170231
Atlanta, Georgia 30317

Please provide the following contact information:

DUES
$45	Member of American Psychological Association Membership No.
$45	Psychologist but not member of American Psychological Association
$45	Physician
$45	Allied professional at or below doctoral level
$20	Actively enrolled psychology student (undergraduate, graduate, post doctoral training) * Faculty Advisors Signature __________________________
$30	Fully retired
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