Member Registration Form

Name: ________________________________________________________________________

Title:   ________________________________________________________________________

Organization:  __________________________________________________________________

Address:         __________________________________________________________________

                        __________________________________________________________________

                        __________________________________________________________________

                        __________________________________________________________________

Phone:             Home / Cell / Work    ________________________________________________

Email:             Home / Work  ______________________________________________________

            Yes, it is okay to include my name and contact information in a NECLP, Inc. Directory.

           I prefer for my information to not be included in the NECLP, Inc. Directory.

Membership dues are $25 annually for professionals, $20 annually for students.

Please make checks payable to:  New England Child Life Professionals, Inc.

Please mail to:            Rachel Alley                          

                                    c/o NECLP, Inc.

                                    328 Main Street

                                    South Hadley, MA 01075