application for student membership - Psychologists` Association of

Membership term April 1 – March 31
Is open to an individual who upon application:
a) is registered as a student in an undergraduate or graduate psychological
program at a recognized university, college, or other institution of postsecondary education; and
b) is of good character and reputation; and
c) pays the prescribed dues
Student Members are eligible for appointment to the Board as a Student Member
Attached application form to be completed.
Include signature of sponsor. Please note that sponsors must be Registered
Proof of enrollment as a student in a program of psychology at a postsecondary educational institution must be included with the application.
Forward completed application to the Psychologists’ Association of
Alberta at the address given above.
Please enclose the Application Fee of $40.00. After May 1st there is a pro-rate in
effect. Please contact the PAA office for details.
The Psychologists’ Association of Alberta subscribes to A Canadian Code of Ethics
for Psychologists, (Revised 2000), Code of Professional Conduct, and Practice
Guidelines for Providers for Psychological Services.
 Male
 Female
Date of Birth:
Mailing Address:
Billing Address:
Business Phone:
(___)_____________ Home Phone: (___)___________________
Degree completed
Year completed
Present Occupational Experience in Psychology:_______________________________________
Memberships in Other Professional Associations: ______________________________________
Have you ever been required to withdraw from membership in a Psychological Association or
any other professional Association? If so, please provide details on a separate page.
Yes [ ]
No [ ]
SPONSORSHIP – Sponsors must be Registered Psychologists
Name of Sponsor (Please print):_____ _______________________________________________
Sponsors’ Comments: ____________________________________________________________
Date: ______________
Signature of Sponsor: ______________________________________
Payment of $40.00 (payable by cash, cheque, Visa, Mastercard or American Express)
After May 1st there is a pro-rate in effect. Please contact the PAA office for details.
Proof of Student Status for current year (photocopy of current transcript or letter from
Member Type:
Student Fee
**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.
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): _________________________________________________________
Method of payment:
 Cheque included with application
 Mastercard
Card Number:
 Visa
 American Express
_____________________________ Expiry Date: __________
Name of card holder: _____________________________
Please send your completed application form and proof of student status to:
Psychologists' Association of Alberta
Unit 103, 1207 – 91st Street SW
Edmonton, AB T6X 1E9
FAX: (780) 423-4048 or Toll Free 1-888-423-4048
Please be sure to include Proof of Student status with your application.
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
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.
Name: _________________________________________________
Location: Edmonton________
 Interest in all General Volunteer
Out of Town_______
 Please identify the area(s) you are
interested in below.
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 –
 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 –
 PAA Biannual
Conference – May
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
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.
Thank you for supporting your professional association!
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)
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
 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