Professional Membership Subscription – California Association for Infant Mental Health

Annual Membership Subscription

Your Professional Membership will renew annually for $100 via automatic PayPal payment. You may cancel your subscription at any time inside the Member Portal, or by going to your PayPal Account. Prefer a one-time membership payment?

Professional Membership: $100, renews each year

Name:*

First Name Required Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Type of Address:* Type of Address is Required

Residence Work

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Primary Phone:* Primary Phone is Required

Alternate Phone: Alternate Phone is not valid

Professional Discipline:* Professional Discipline is Required

What county do you live in?:* What county do you live in? is Required

What county do you work in?:* What county do you work in? is Required

Do you provide services in other languages other than English?:* Do you provide services in other languages other than English? is Required

Yes No

If so, lease list all languages:: If so, lease list all languages: is not valid

Area of Expertise/Interest:* Area of Expertise/Interest is Required

Clinical Intervention Public Policy Public Relation / Communication Strategic Planning Training & Education

Would you be interested in Volunteering for CalAIMH?:* Would you be interested in Volunteering for CalAIMH? is Required

Yes No

Have you been endorsed by California Center for Infant-Family & Early Childhood Mental Health Specialist (IFECMHS)?:* Have you been endorsed by California Center for Infant-Family & Early Childhood Mental Health Specialist (IFECMHS)? is Required

Yes No

If so, what level of endorsement?: If so, what level of endorsement? is not valid

Transdisciplinary Mental Health Practitioner (TMHP) Mental Health Specialist (MHS) Reflective Practice Facilitators I (RPF I) and Reflective Practice Facilitators II (RPF II) Reflective Practice Facilitator Mentor (RPFM)

If not, are you interested in becoming endorsed?: If not, are you interested in becoming endorsed? is not valid

Yes No

Are you a member of Infant Development Association (IDA)?*:* Are you a member of Infant Development Association (IDA)?* is Required

Yes No

Are you a member of the World Association for Infant Mental Health (WAIMH)?:* Are you a member of the World Association for Infant Mental Health (WAIMH)? is Required

Yes No

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Pay via your PayPal account

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$100 / Year

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	Professional Membership Subscription – Initial Payment $100 / Year	$100.00
	Total	$100.00

Professional Membership Subscription – Initial Payment

$100 / Year

$100.00

Total

$100.00