A branch of the American Counseling Association
o New Application q Do not publish my address
o Renewal information in the Directory
o Ms. Please Print Clearly o Do not release my information
o Mr. to any mailing service
Name: o Dr. ___
Last First MI
Membership Type: o (1) Professional / Regular o (2) Retired *o (3) Student ** q(4)New Professional***
* The applicant has retired from a counseling position and is working less than 15 hours per week.
** The applicant listed above is a student in a counseling program and is not currently practicing as a counselor. (Professor’s information and signature required for membership discount)
*** The applicant has recently graduated with a degree in counseling (first year’s membership is free but this requires a copy of the applicant’s transcript or a written statement from Professor)
Signature of Professor Name
Institution Date
Contact Information:
( )
*Email Home Phone
( )
Address Line 1 Work Phone
( )
Address Line 2 Fax
_________________________________________________________________________ ( )
City State Zip Code + 4 Cell Phone
*Please make sure your email address is current and is one that you check frequently as this is the primary method of communication that will be used to update your information and keep you informed of TCA events. If changes need to be made please contact Becky Murray, Executive Director, at bmurray48@hotmail.com and she will be happy to update your information.
Committee Interests:
oAdvocacy oBy-Laws oLicensure oPublic Relations
oArchives oEthics & Human Rights oMembership oTechnology
oAwards oFinance oPublications
Please check all that apply: How did you learn about TCA?
Certification: NCC NCSC q TCA officer qTCA Member
Licensure: LPC MHSP LMFT LCSW q a professor
Are you a current ACA member? Yes No q website
Are you a current TEA member? Yes No q Listserv q Other
TENNESSEE COUNSELING ASSOCIATION
A branch of the American Counseling Association
DO NOT USE AFTER JUNE 2009
Dues Information: TCA membership includes the state plus one chapter and one division of your choice.
Additional Chapters may be joined at a cost of $15.00 each.
Additional Divisions may be joined at a cost of $20.00 each.
Please place a check mark in the appropriate box to indicate your primary chapter and primary division affiliation. To indicate one or more additional affiliations, please mark those as well and calculate your extra dues in the area below.
Chapter Membership – Division / Organizational Affiliate* Membership –
o Cumberland Counseling Association o TAADA * - Association of Adult Development and Aging
o Lookout Counseling Association o TAAOC * – Association of Addiction and Offender Counselors
o
Martha Polk Counseling Association
o TACES -
Association for Counselor Education
and Supervision
o Middle Tennessee
Counseling Association o
TAMCD – Association for Multicultural Counseling
and
o Smoky Mountain Counseling Association Development
o South Central Counseling Association o TAMFC * – Association of Marriage and Family Counselors
o South Tennessee Counseling Association o TCDA * – Career Development Association
o Watauga Counseling Association o TMHCA – Mental Health Counselors Association
o West Tennessee Counseling Association o TSCA – School Counselor Association
* Effective July 1, 2003, these organizations that have less than 40 members become Organizational Affiliates rather than Divisions. The TCA Past President represents the Organizational Affiliates on the Executive Council.
TCA State Dues - This includes your primary chapter and division dues. $ 65.00
Additional Chapter Dues ( $15.00 each ) $
Additional Division Dues ( $20.00 each ) $
Sub-Total [ TCA and Additional Chapter(s) / Division(s) Dues ] $
* Discount for Retired membership – Divide Sub-Total in half *
** Discount for Student membership must be validated on Page one of this form – Divide Sub-Total in half **
*** First year’s membership is free for new graduates in counseling- must submit documentation(transcript or professor’s statement)
Total Amount Due $
Method of Payment
o Check made payable to: TCA Check Number
- - - - - or charge my - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
o Visa Card Number Expiration Date
o MasterCard
Name on Card
Signature Date Authorized
I agree that the information provided on this application is correct and as a professional member of TCA I will adhere to the American Counseling Association Ethical Codes and Standards of Practice.
Signature Date