NCABA Workshop Registration Form

Instructions: You can use the form below to become a member of NCABA and/or to register for the workshops offered in September. Please complete all information. Be sure to submit your entry when it is complete by pushing the submit button at the bottom of the page. When you submit the form you will be asked to choose your payment method (mail, fax, phone, and online payment by check are available). Your registration is not complete until payment has been received. Membership registration below is for the period of January 1st through December 31st 2010. If you have trouble submitting this form please make sure you are using Internet Explorer 8, Mozilla or Firefox as your internet browser or contact the web manager at help@nc-aba.com.

Full Name: Affiliation:
Mailing Address:
City: State: Zip Code:
Email: Home Number:
Work Number: Fax Number:
Major Field of Study: Highest Degree Earned:
Licensure or Certification: Specialty Area:
Check One: Membership Renewal Renewal with Changes New Application Not Applying for Membership
Membership Fee: None (Choose this option if you are registering for the workshops only)
Full Membership = $20.00 (Anyone interested in the study of behavior analysis or employed in a profession or vocation that utilizes the principles of behavior analysis, these individuals may vote and hold elected office)
3 Year Full Membership = $50.00 (anyone wishing to pay in advance for full membership for three years)
Paraprofessional/Parent Membership = $10.00 (available for individuals who are not academically trained in the study of behavior analysis, these individuals are eligible for reduced membership rates, but may not vote or hold elected office)
3 Year Paraprofessional/Parent Membership = $25.00 (anyone wishing to pay in advance for paraprofessional/parent membership for three years)
Student Membership = $10.00 (a student who is currently enrolled in a course of study on at least a half-time basis at an accredited college or university who is interested in the application of behavioral principles)

Workshop Fee:
(check all that apply) 		*Workshops below are co-sponsored by the North Carolina Psychological Association and the North Carolina Association for Behavior Analysis. The North Carolina Psychological Association is approved by the American Psychological Association to sponsor continuing education for psychologists. The North Carolina Psychological Association maintains responsibility for these workshops and their content. Each workshop is offered for 3 hours of continuing education credit. In addition, each workshop is BACB approved for 3 hours of Type II continuing eduction credits.
*Ethics Workshop I (Schell) Winston Salem: Fri.. September 24th 9:00 AM (click here for description)
*VB Workshop II (Stafford) Winston Salem: Fri. September 24th 1:30 PM (click here for description)

Fee for One Workshop: if submitted on or before 09/06/10 = $55.00 if submitted after 09/06/10 = $80.00
Fee for Two Workshops: if submitted on or before 09/06/10 = $90.00 if submitted after 09/06/10 = $130.00

Student Workshop Rate: if submitted on or before 09/06/10 = $25.00 if submitted after 09/06/10 = $30.00
Student Workshops Rate: if submitted on or before 09/06/10 = $45.00 if submitted after 09/06/10 = $50.00

Calculate total owed from both fee sections above. Please record the amount here and remember it so that you can complete payment after you submit this form. Total Amount Owed : $