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Questions  Email: membership@ispn-psych.org  •  Phone: (608) 443-2463

Membership year is July 1 through June 30

Annual Dues Renewal Date for all members is July 1st.

ISPN Homepage  •  MembershipForm Instructions

Note: All fields labeled in Red are required to process this application.

First Name:

Middle Initial/Name:

Last Name:

 

ISPN Member Status:

 (July 1st through June 30th)

Credentials:

Title:

Institution/Affiliation:

Business/Affiliation Address:

Business Address:

 Business Address 2:

Business City:

 

Business State or Province:

 

Business Zip:

Business Country:

 (Leave blank if USA)

Home Address:

Home Address:

Home Address 2:

Home City:

   

Home State or Province:

 

Home Zip:

Home Country:

 (Leave blank if USA)

Preferred Mailing Address:

  Business/Affiliation     Home

Home Phone:

Daytime Phone:

Fax:

Email:

Referring Member:

The following line of questions are optional and for demographic analysis only:

Gender:

  Male      Female

Race/Ethnicity:

Highest Degree:

Years in Practice:

Student:

  Yes |    No  (must send verification of student status(copy of ID, schedule, etc) to ISPN office)

ANA Member:

  Yes |    No  

ANA Member #, if yes

 (Required if ANA Member)

ISPN Member#:

 (please give us your member # if you are an ISPN Member)

Do you have prescriptive
authority in your state?

  Yes |    No

ANCC Certification:

 Adult PMHNP  |  Family PMHNP  |  Adult PMHCNS  |  ChildPMHCNS

Dues Calculation

Membership Type:

 ISPN Membership Types

Areas of Interest

My Research Interest is:

My Clinical Interest is: 

My Population Focus is:

I currently act as an ISPN liaison to these professional groups or organizations (optional):

How did you hear about ISPN?

I am interested in participating in the following committees (optional):

Awards Committee:

Marketing & Development Committee:

Communications Committee:

Membership Committee:

Conference Committee:

Nominating Committee:

Diversity and Equity Committee: 

Website Management Committee: 

Finance Committee:

 

 

Charitable Donation

If you are interested in making a donation to ISPN, select one button under Amount and one button under Donation Type.

 

 

Donation Type

 

Amount

By checking this box, you are pledging a total of $500 to the ISPN Foundation
  New Lamplighter Commitment ($100 for 5 years - $500 total donation)
  Payment to existing
Lamplighter Commitment

More Information >>

 

  $1000.00

  General Contribution

 

  $500.00

  Mental Health and Wellness Research Scholarship

 

  $300.00

  Hertha Gast Scholarship

 

  $200.00

  Carol Williams Memorial Scholarship Fund

 

  $100.00

  Susan McCabe Lecture Fund

 

  $50.00

  Greatest Need

 

  $25.00

  Sustained Giving (Annual donation)

 

 Other Amount
(Enter whole dollars only, e.g. 35)

  NONE : Clear above button selection

 

  NONE : Clear above button selection
To clear “Other’ Dollar Amount, please remove it.

 

Periodically corporations, institutions, and healthcare recruitment agencies ask ISPN to provide the ISPN
membership for mailings.  Please check here if you do not wish your name and address to be included.

  Please do not release my name and address to corporations, institutions, or agencies outside ISPN.

 

May ISPN send you updates, such as conference abstract submission opening and closing dates; Award and Officer nomination, election results; and conference information (hotels, registration, program/schedule updates, etc.)?

Yes  | No  

 

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ISPN Member Application Form