Palm Beach Association
of School Psychologists
PBASP MEMBERSHIP APPLICATION 2014-15
MEMBERSHIP YEAR AUGUST 12, 2014 – August 12, 2015
CONTACT INFORMATION:
NAME:
HOME PHONE #
CELL PHONE #
HOME ADDRESS
PERSONAL EMAIL ADDRESS
DUES (Check One):
 Regular Member
 CE Member*
 Retired Member (Non-CE)
 Retired Member CE
 Student Member
$25.00
$50.00
$15.00
$50.00
$15.00
*CE membership for licensure/NCSP
Palm Beach Association
of School Psychologists
PBASP CE Standards of Practice:
PBASP is approved by the Florida Agency for Health Care Administration (AHCA) to offer Continuing
Credits toward license renewal for its continuing education offerings. PBASP is also a NASP approved
provider and offers NASP approved courses toward NCSP renewal. PBASP members, who attend an
entire workshop, complete an evaluation form for the program, provide their license number and verify
their attendance at the entire workshop by signing in and out of this workshop may earn credit. Sign in
sheets will be available approximately 30 minutes prior to the start of the workshop. Partial credit will not
be provided. At the workshop sign-out (when the speaker concludes), each program attendee will be
asked to turn in a completed evaluation form at which point each attendee will receive a certificate of
attendance.
PBASP is here to help serve our members by providing quality continuing educational opportunities for
on-going professional development. If you have any questions regarding licensure or Nationally Certified
School Psychologist (NCSP) renewal, please do not hesitate to contact the Continuing Education
Coordinator or a PBASP board member.
By signing below, you agree to abide by the CE standards of practice for PBASP.
______________________________________________
_________________________
PBASP Member Signature
Date
Make checks payable to: “Palm Beach Association of School Psychologists”
PONY TO:
Maria I. Iglesias, School Psychologist
Delray Full Service
MAIL TO:
Maria I. Iglesias
2900 N.E. 56th Court
Fort Lauderdale, FL 33308