Membership Application

Please complete and submit this membership application form.

Section 1: Biographical Information (Both new and renewal applicants should complete this section.)

Type of Membership:NewRenewal

Date:

Name:

Address:

Phone Number:

Email:

May we have your permission to post your above email address on the NAFA website for public view?YesNo

If No, may we have your permission to make this information available only behind the  "Members Only" link on the NAFA website? YesNo

Committee preference:

Membership and Recruitment   Research   Marketing  
Ethics   Website North America Implementations  
Other

Section 2: Training

If this is a renewal membership, would you like to update any information in this section? YesNo (New members should not respond to this question.)

If you answered NO to the previous question, scroll down and complete the questions in Section 3: Dues & Payment. Otherwise, please complete the following questions.

Please check levels of FIE training completed:

Basic I

Basic II

Standard Level I

Standard Level II

Standard Level III

LPAD I

LPAD II

Basic Trainers I

Standard Trainers I

Standard Trainers II

LPAD Trainers I

LPAD Trainers II

Other

What are your special area(s) of Interest in FIE?

ATC Affiliation (if applicable)

Do you want to be listed as a Practioner on the NAFA website? YesNo

If yes, in which geographic area(s)? East  South  Midwest  West  Canada

Do you want to be listed as a Trainer on the NAFA website?YesNo

For which levels?Basic Standard

If yes, in which geographic areas? East  South  Midwest  West  Canada

Section 3: Dues & Payment:  (Note: Membership dues are for one year: September 1 to August 31)

Individual: $50   Student: $25   Couple: $50

Institution (10-30): $300 (List names and email addresses below)

How do you plan to pay for your dues?
check or money order Credit Card or PayPal2016 New Trainee Membership Waiver


Important:  Your application is not complete until you submit this membership application form and pay your dues. After you submit this form, a confirmation screen will appear which will provide information about how to pay your dues.

We appreciate your help in expanding our membership and are sure that you will be glad you joined the North American Feuerstein Alliance.