Membership Form

CHECK ONE
New Application Renewal

PART ONE: YOUR NAME, PREFERRED MAILING ADDRESS, AND EMPLOYMENT INFORMATION
Name
Address
City, State, Zipcode
Home Phone
Email Address
Facility
Facility Address
Facility City, State, Zipcode
Facility Phone

PART TWO: YOUR FORM OF PRACTICE AND MEMBER SUPPORT GROUPS

Residential Facility
Older Adults
Nursing Home or SNF
Mental Health
Hospital
OT Education
Private Practice
Pediatrics/School-Based
Retired
Rehabilitation Services
School-Based
  
OT Education
  
Home Health
  

PART THREE: THE OOTA DISTRICT YOU PREFER

Akron
Cleveland
Dayton
Southeast
Cincinnati
Columbus
Northwest
Youngstown-Warren

Note: Membership in one district is included in your dues. Membership in additional districts requires a fee of $8.00 per district.

PART FOUR: MEMBERSHIP DUES

PLEASE CHECK YOUR CATEGORY
OT
Occupational Therapist
$60.00
OTA
Occupational Therapy Assistant
$50.00

STUDENT

 
Enrolled in an accredited OT or OTA Program

School               
Graduation Date
$25.00
ASSOCIATE
Healthcare Professional Interested in Promotion of Occupational Therapy.
$70.00

PART FIVE: OPTIONAL FEES

Additional district membership(s) Membership in one district is included in your membership fees. Additional district memberships are $8.00 each.
Sustaining Member
A gift of at least $10 in addition to dues
Scholarship
 A gift to assist OT or OTA students
Membership Book For Student or Associate Members
$10 each. The 2008 book will be printed in June, 2008.

PART SIX: METHOD OF PAYMENT

Your total for Membership Dues and Optional Fees:

Please fill in VISA or MASTERCARD information below.

Visa      MasterCard

Card Number - - -        Security Code from back of card

Expiration /