NAPSW APPLICATION FOR MEMBERSHIP
Name_____________________________
Degree_____________ Title_________________
(Last)
(First)
(M.I.)
Mailing Address:
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Preferred Mailing Address:
__________________________________
__________________________________
__________________________________
__________________________________
Phone: (____) _______________________
Fax: (____) _________________________
Email Address: ____________________________
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Secondary Mailing Address:
__________________________________
__________________________________
__________________________________
__________________________________
Phone: (_____) _____________________
Fax: (____) ________________________
Email Address: ____________________________
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Check appropriate status:
| __ Regular Membership ($75.00) |
__ Associate Membership ($50.00) |
| Open to social workers with a bachelor's, master's, or doctorate degree in social work and currently
employed in a perinatal health care setting, or
private practice. |
Open to persons who do not have social work degrees, but
who function as social workers in a perinatal
health care setting; OR have a doctorate, master's or bachelor's degree in
social work, who are not employed in a perinatal
health care setting, and have an interest in the goals and objectives of the
association |
| __ Student Membership ($25.00) |
__Retired
Membership ($35.00) |
| Open to students or trainees in a bachelor's, master's or doctorate program accredited by the Council on
Social Work Educators, and who are receiving field instruction in a perinatal
setting. |
Open to social workers with a bachelor’s master’s or
doctorate degree in social work, OR to persons who have functioned in the
past as social workers in a perinatal health care
setting, who are age 62 or older, no longer employed, and have an interest in
the goals and objectives of the association. |
How, or from whom, did you hear about us:
________________________________________________
Employment:
Present Employment:
________________________________________________________________
Area of Specialization:
_______________________________ Years in current position:
______
____ Full-time ____
Retired ____
Unemployed _____ Not Employed as a Social
Worker
____ Part-time ____ hours a week ____
Student ____ Not employed in a Perinatal
Setting
Previous Employment: (attach additional
sheet if necessary)
Agency/Institution:
__________________________________________________________________________
Address:
__________________________________________________________________________
Position/Title: __________________________________________________________________________
Length of Employment: ___________________________
Education:
Degree Year
College or University, City and State
Speciality/Major
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Date entered degree program: ______________ Date degree anticipated:
_________________
I understand that falsification of the contents of this application will be
grounds for rejection and/or termination of my Association Membership and
revocation of any and all benefits resulting there from.
_____________________________________________________
_____________________
Signature
Date
Checklist: Please submit all of the
following materials when requesting membership:
________ Completed membership application form
________ Membership fee payable to NAPSW (U.S. funds only)
________ Documentation of Degree (e.g., copy of diploma, ACSW certificate,
letter of confirmation from employer or social work school, or copy of State Licensure)
Submit these
materials to:
Irene Bruskin, MSW
NAPSW Membership Chair
Children's Hospital of New York Presbyterian
3959 Broadway - CHN T757
New York, NY 10032
membership@napsw.org
Phone 212-342-8594
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