Student Affiliate Application

Please read Student Affiliate Application Instructions before completing this application.

 
Contact Information
(*Required field)
PrefixFirst*MiddleLast*Suffix
Name: *
Country:*
Address: *
 
 
City:*
State/Province:*
Zip/Postal Code:*
Email:*
Please reenter Email for verification:*
Name of School:*
Date of birth:*
(MM/DD/YYYY)
Gender:*
Male    Female   Transgender
We require either a work phone number or a home phone number to facilitate follow-up:*
e.g., (123) 123-4567 or +1 123 456 4567
 Work Phone:   Ext:       Home Phone:   Ext:       Fax:
Your affiliation with APA is considered part of the public record. Your contact information will be listed in the APA Membership Directory. If you wish to publish only your name in the directory, please check here.
 
Student Status
What is your status for the 2014 academic year?*
What degree are you expecting to attain?*
Major Field:*
I expect to receive my degree (or have received my degree) in:*
20 (YY)
If you are currently a master's level student or in a master's program, do you intend to pursue a doctorate?
Answer the following question ONLY if the graduate degree for which you are currently enrolled is a health-service provider subfield (e.g., clinical, counseling, school, etc.)
Do you intend to seek licensure / certification by a state / provincial board of psychological examiners?
 
Student Affiliate Fee*
Undergraduate $35.00
Undergraduate with Affiliation with APAGS $57.00
Graduate $57.00
Other Information
What is your ethnicity? (Mark all that apply):
American Indian/Alaskan Native   Asian, or Pacific Islander Caucasian/White  
African American/Black Hispanic/Latino   Other

For Undergraduate and Graduate Students Only
Have you at any time been convicted of a felony, sanctioned by any professional ethics body, licensing board, or other regulatory body by any professional or scientific organization?* Yes    No
If yes, please explain:
(Only first 350 characters will be submitted)
 
What's your main reason for joining APA today? *
 I received an e-mail or promotion in the mail from APA
 I was referred by professor, friend or colleague
 My school requires it
 I joined on my own

In making this application, I subscribe to and will support the objectives of the American Psychological Association as set forth in Article I of the Bylaws, and the Ethical Principles of Psychologists and Code of Conduct, as adopted by the Association, and I affirm that the statements made in this application correctly represent my qualifications, and understand that if they do not, my affiliation may be voided.

The Ethical Principles and Code of Conduct is available on APA's Web Site at http://www.apa.org/ethics/code/index.aspx.

The Bylaws are available at http://www.apa.org/about/governance/bylaws/index.aspx.

Indicate your agreement:*  Yes     No