Membership Application Forms

High School Student Affiliate Application

Please note: This is not an online application. Please fill out the application, print, sign and date it, and mail it with payment.

Please read High School Student Application Instructions before continuing.

GENERAL INFORMATION
First Name
 Middle Name
 Last Name
Mailing Address Line 1
Mailing Address Line 2
City
 State
 Zip Code
Phone (with area code)
 Fax (with area code)
  
Email Address
 
Your affiliation with APA is considered part of the public record. Listings of your affiliation may be produced at any time. If you do NOT wish to have any contact information released or made public at any time, please check here.

 

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Applicant's Signature

 

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Date

STUDENT STATUS

Please provide us with the following information so that we may better serve you:
Female Male  
 

Please mark ONE alternative that best describes your status for the 2007 academic year (July 1, 2006 - June 30, 2007):

 

What is your ethnic heritage? (Mark all that apply)
American Indian or Alaska Native
Asian, Asian American, or Pacific Islander
African American/Black
Hispanic/Latino
Caucasian/White
Other (Specify)

PAYMENT INFORMATION

I have enclosed a check or money order in the amount of $27.00

I authorize APA to charge my High School Student Affiliate fee to the credit card as listed below.
Cardholder Name
Credit Card Billing Address Line 1
Credit Card Billing Address Line 2
City
 State
 Zip Code
Daytime Phone (with Area Code)
Amount To Be Charged
 Type of Credit Card
American Express  MasterCard  Visa
Account Number
 Expiration Date

Signature (sign below - required for all charge orders):

 

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Once you have completed this form, please print it out, sign and date it, then return the completed application, with payment (by check, money order, or credit card, drawn on a US bank in US dollars, made payable to the American Psychological Association).

Mail to:
American Psychological Association
Membership
750 First Street, NE
Washington, DC 20002-4242

Applications accompanied by credit card payments may be faxed to (202) 336-5568.

For questions regarding this application, contact APA at (202) 336-5580, (800) 374-2721, Email: Membership, or TDD/TTY (202) 336-6123.

For more information about APA's student programs, please visit APA Resources for Students.

High School Student Affiliate Description

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© 2008 American Psychological Association
Membership Department
750 First Street, NE • Washington, DC • 20002-4242
800-374-2721 (US & Canada Toll Free) • 202-336-5580 (in DC) • TDD/TTY: 202-336-6123
202-336-5568 (FAX) • Email
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