PSYCHOLOGICAL ASSISTANT AFFILIATE
Membership term April 1 – March 31
PSYCHOLOGICAL ASSISTANT AFFILIATE MEMBERSHIP (non-voting)
Is open to an individual who at the time of application:
a) practices within the scope of practice of psychology (as defined in Schedule 22 of the
Health Professions Act);
b) practices under the supervision of a registered psychologist;
c) holds a Bachelor’s Degree;
d) is of good character and reputation;
e) subscribes to and supports the objectives of the Psychologists’ Association of Alberta,
Canadian Code of Ethics for Psychologists (Revised 2000), Standards of Practice, and
Practice Guidelines for Providers for Psychological Services; and
f) pays the prescribed dues.
Procedure:
An application form should be completed and forwarded to the Psychologists’ Association of
Alberta.
Applications must be accompanied by the following documents:


Official transcripts of educational qualifications
Recent criminal record check (within the last 6 months). Criminal record checks are only
accepted if they are provided by a police agency (we do not accept criminal record
checks processed by private companies).
Please enclose the application fee of $190.00. There is a pro-rate in effect after May 1st for new
applicants. Please call the PAA office for details.
The Psychologists’ Association of Alberta subscribes to A Canadian Code of Ethics for
Psychologists (Third Edition, Revised 2000), Code of Professional Conduct, and Practice
Guidelines for Providers for Psychological Services.
APPLICATION FORM
PSYCHOLOGICAL ASSISTANT AFFILIATE
Date:
_____________________________
Name:
______________________________________________________
 Male
 Female
Mailing Address:
______________________________________________________
____________________________________PC_______________
Billing Address:
______________________________________________________
______________________________________PC_____________
E-mail:
______________________________________________________
Business Phone:
(___)_____________ Home Phone: (___)___________________
E-mail
__________________________________________________________
Current Principal Employment: _____________________________________________
Work Address: ___________________________________________________________
___________________________________________________________
Academic History
Highest related Degree
Department/Faculty
___________________
_______________________
____
____________
___________________
_______________________
____
____________
___________________
_______________________
____
____________
Year
Institution
Memberships in Other Professional Associations:
__________________________________
___________________________________
__________________________________
____________________________________
Have you ever been required to withdraw from membership in a Psychological Association or
other professional association or at any time been convicted of a felony, sanctioned by any
professional ethics body or other regulatory body or by any professional or scientific
organization?
[ ] Yes [ ] No
If yes, please provide details on a separate sheet
________________________________________________________________________
Name and signature of Supervisor (must be a Registered Psychologist)
Name
Signature
__________________________________
____________________________________
In making this application, I subscribe to and will support the objectives of the Psychologists’
Association of Alberta, Canadian Code of Ethics for Psychologists (Revised 2000), Standard of
Practice, and Practice Guidelines for Providers for Psychological Services. I recognize I am not
a psychologist, nor may I present myself as one or use my status with the Psychologists’
Association of Alberta to misrepresent my professional standing. I affirm that the statements
made in this application correctly represents my qualifications for membership, and understand
that if they do not, my Psychological Assistant Affiliate status may be voided.
Applicant’s Signature: _______________________________ Date: ________________
Work Setting (please check all that are applicable):
Private Practice ____
Schools ____
AB Gov’t Social Service Agency ____
Business/Corporate ____
Private agency NGO ____
WCB ____
EAP/EFAP agency ____
Unemployed or retired ____
Corrections ____
Leave (e.g. maternity or sick leave) ____
Universities/Colleges ____
AHS Comm. Mental. Health ____
AHS/Covenant Health - Hospital or Clinic ____
Federal Gov’t (other than corrections, e.g. FNIH, RCMP ____
Primary Care Network/Family Care Clinic, or Shared Care ____
Other (please specify): _________________________________________________________
APPLICATION FEE AND NECESSARY DOCUMENTATION MUST ACCOMPANY
THIS APPLICATION
Member Type:
Psychological Assistant Affiliate
$190.00
Total:
________
**Membership year runs from April 1 through March 31. After May 1st there are pro-rated fees
available to new members only. Please contact PAA office for pro-rated quote before
submitting application.
Method of payment:
Amount:




Card Number:
________________
Cheque included with application
Mastercard
Visa
American Express
_____________________________ Expiry Date: __________
Name of card holder: _____________________________
Signature:
_____________________________
Please send your completed application form to:
Psychologists' Association of Alberta
Unit 103, 1207 – 91st Street SW Edmonton, Alberta T6X 1E9
EMAIL: paa@psychologistsassociation.ab.ca
FAX: (780) 423-4048 or Toll Free 1-888-423-4048
IMPORTANT INFORMATION!
Personal Information Protection
When you apply for membership with PAA, we collect personal information such as your name,
address, phone numbers (business/home/fax), email address, CAP registration #, Highest Degree
earned and Birthdate and use it to:




Confirm your identity
Establish membership with PAA
Provide ongoing member services and communications
Determine eligibility for life membership through birthdate information
From time to time the PAA provides mailing lists to advertisers. Before advertisers are given
access to a PAA mailing list, they are required to provide information on the proposed mailing
and to agree that if permission to use the list is granted, that it will be used for a single mailing
only.
Please check the applicable box below. If you check the box whereby you do not want to be
included in non-PAA communications, your name will not be given out and will only be used for
mailings coming out of our office. This may, however, cause you to miss some information
about non-PAA workshops and conferences, goods and services available for PAA members, as
these are the types of information that may be mailed to you.
If we do not receive a response from you, we will automatically assume that you do not wish to
receive external communications. Your records will continue to indicate the choice made until
such time as you advise us in writing to either remove your name from the external mailing lists
or alternatively, until you provide your consent to add your name to the external mailing lists.


Please do not include me in PAA mailing lists for non-PAA communications.
Yes, I wish to be included in PAA mailing lists for non-PAA communications and give
my consent to provide my mailing information.
______________________
Date
____________________________________
Signature
PAA VOLUNTEER OPPORTUNITIES
Name: ________________________________ Member Type: _____________
Location: Edmonton________
Calgary_______
 Interested in all General Volunteer
Opportunities
Out of Town_______
 Please identify the area(s) you
interested in
PAA Committee Volunteer Opportunities
 PAA Psychologically Healthy Workplace Committee
 PAA Public Education Committee
 Other PAA Committees/Task Forces that may arise
Specific events with approximate time frame of the year:

Learning Disabilities
Association of Alberta –
November.

Calgary Teachers
Convention – February

South Western Teachers
Convention – February

Edmonton Teachers
Convention – February

Edmonton Regional
Science Fair – April

Alberta College of
Family Physicians –
February

Calgary Youth
Science Fair –
April

The Central Alberta
Regional Science Fair
–March

PAA Biannual
Conference – May
IMPORTANT INFORMATION!
Privacy Legislation for Marketing
We have previously asked you to provide us with your choice as to whether or not you wished to be placed on the
mailing lists for non-PAA communications. If we did not receive a response from you, we automatically assumed
that you did not wish to receive external communications. If you indicated that you did want to receive non-PAA
communications, we have indicated this on your records in our database.
If you wish to change your selection for non-PAA communications, please contact our office in writing. Otherwise
if you are currently receiving non-PAA communications, you will continue to do so until you advise us otherwise.
If you are not receiving non-PAA communications and you wish to start receiving them, please contact us in writing
providing consent to add your name to the external mailing lists.
If you are uncertain as to the choice you have previously selected, please do not hesitate to contact the PAA office
and we will confirm this with you.
Fax-Back Cover Sheet
Fax to:
Psychologists' Association of Alberta
Fax Number:
(780) 423-4048 (Edmonton Area) or
1-888-423-4048 (toll free across Alberta)
From:
_____________________________________
Number of pages: 1
PAA Newsletter – Psymposium
The PAA newsletter, Psymposium, is published three times per year (April,
August and December). Psymposium is available online on our website.
Would you like to choose to read Psymposium online rather than receive a
paper copy? If you would prefer to read Psymposium online, we will contact
you by email advising you when the most current copy of Psymposium has
been posted. Please indicate your choice below. If you prefer online we will
require you to provide your email address below:
 Online
Or
 Paper Copy
Name: _______________________________________________________
(please print)
Email address:
_____________________________________________________________
(please print)
Confidentiality Notice:
This transmission contains confidential information and is only intended
for the Psychologists’ Association of Alberta. If it is received elsewhere
by mistake please contact the Psychologists’ Association of Alberta
immediately at the telephone numbers listed above. Thank-you