Date:

*Username:
*Password:
*Confirm Password:
*First Name:
*Last Name:
Degree/Credentials:	(ex: MA, PHD, LPC)
Other Professional Memberships:
*Address:
*City:
*State:
*Zip:
*Day Phone:
Evening Phone:
*Cell Phone:
Fax:
*E-mail:
Current Occupation/Activity/Counseling Speciality:
*I would like this information published on the ACAM-KC website:	Yes No
*Plese indicate what type of membership:	Professional Membership Student Membership
Payment Information
In order to complete the application a check of the value of $10.00 must be received:
Please make all checks payable to: ACAM-KC 11010 McGee Kansas City, MO 64114 If you have any questions, please e-mail Traci Klasing at traci.klasing@park.edu
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