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Membership Application & Questionnaire
Date:	mm/dd/yy
Name:
Degree:
Profession:

Agency (If applicable)
Home or Work Street Address:
City:
State:
Zip Code:
Work County:

Work Phone:
Work Fax:
Email Address:

Do you want your information to appear on our website please: YES NO

Please select member categories: (UAIMH, WAIMH or Both)
	UAIMH	WAIMH
Regular Regular with Journal Student** Student with Journal	$10 N.A $10 N.A	$70 $115 $40 $85
Are you a member of WAIMH? Yes No
If yes would you like to submit your dues through us?** Yes No
	UAIMH dues	WAIMH dues	Total dues submitted
Totals:	$ +	$	=

Please choose your main areas of interest: (circle no more than 5)
01 Adolescent pregnancy 02 Adoption Issues 03 Affective Development 04 Anxiety/Inhibition 05 Attachment Theory and issues 06 Autism 07 Child Abuse 08 Child with chronic illness 09 Childhood Psychosis 10 Cognitive Development 11 Cross-Cultural Studies 12 Depression 13 Developmental and behavior pediatrics 14 Developmental Psychopathology 15 Divorce and remarriage 16 Early Childhood programs 17 Failure to thrive 18 Family processes 19 Fathers 20 Feeding disorders 21 Foster care 22 Infants - disabled, special needs, and developmental delays 23 Infants - at risk medically, socially, etc. 24 Infant and toddler day care 25 Infants with mentally ill mothers 26 Infant mental health services 27 Infant - parent interaction 28 Infant observations and experimental research 29 Infant/Mother/Therapist interaction 30 Mental retardation and learning disabilities 31 Normal and abnormal preschool development 32 Nutrition 33 Pediatric care 34 Pediatric physiotherapy 35 Prenatal loss 36 Pregnancy and prenatal period 37 Prenatal development 38 Prevention and early intervention 39 Professional development, treatment issues, supervision 40 Public policy 41 Sex role development, sex differences 42 Sibling relationships 43 Sleep disorders 44 Socialization and discipline 45 Temperament 46 Transitions to parenthood 47 Triadic interventions 48 Violence 49 War children 50 Other

*** Members of the WAIMH can earn money for the affiliate (UAIMH ). An amendment adopted by the board of directors allows for $7.50 to go to UAIMH Would you like this amount to be rebated to UAIMH? YES NO

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