Membership Application Name * Home Email Address * Type of Membership * Regular Member - $25.00 Student Member - $15.00 Retired Member - $15.00 Associate Member - $15.00 Please check all certifications which currently apply to you. Nationally Certified School Psychologist Licensed School Psychologist Licensed Clinical Psychologist Broward County Recognition Program Other License Number Other Certification Would you be willing to serve on a BASP Committee? Yes No Would you be willing chair a committee? Yes No Please indicate which committee you are interested in: Social Events (Annual Holiday and End of Year Luncheons) Community Service (Valentines Day Party, March of Dimes Walk, etc.) Professional Development Committee (Plan for trainings, coordinate CEUs, etc.) CEU coordinator (Keeps records and inputs information into CE Broker) School Psychology Week (Help promote School Psychology Week) BASP Website and Technology Needs Membership Coordinator (Works with Executive Board to keep records) BASP hopes to offer a few training opportunities throughout this school year. Please write down some topics that you would be interested in. Please make checks payable to BASP and Pony this form with the appropriate dues to: Beth Pomertantz at Psychological Services If you are human, leave this field blank.