Name(Required) First Last Home Email(Required) Type of Membership(Required) 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.(Required) Nationally Certified School Psychologist Licensed School Psychologist Licensed Clinical Psychologist Broward County Recognition Program Other Other Certifications(Required) Would you be willing to serve on a BASP Committee?(Required) Yes No Would you be willing chair a committee?(Required) Yes No BASP hopes to offer a few training opportunities throughout this school year. Please write down some topics that you would be interested in.Payment Options(Required) Pay by Check (Payable to BASP) - Pony to: Beth Pomertantz at Psychological Services Venmo: @Beth-Pomerantz1 or 954-854-5881 Zelle: 954-854-5881
