Personal Information First Name: Middle Name: Last Name: Email Address : your email will be your login username Password : Home Address: City: State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Home Phone: Cell Phone: Employment District/Agency/University: Job Title: Address: City: State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Work Phone: Work Email: Education (Select highest held degree) Hightest Degree:
BSW
BA
BS
MSW
MS
DSW
PhD
Other (Specify Below)
Other Degree: Graduation Year: College or University: City: State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Demographics Ethnic/Racial Origin:
African American/Black
Asian American or Pacific Islander
Latino Hispanic
Native American
White/Caucasian
Multi-Ethnic
Other (Specify Below)
Other: Additional Affiliations
Social Work Practice Areas Primary Practice Level & Area (check as appropriate)
Involvement Opportunities Please check if you would consider assisting the Association in any activities below Board Committees
Other
Membership Categories & Dues
A person who meets a state's requirements for the position of school social worker (however that position is titled in a given state) or who has an MSW, and is actively employed by a public or private school or state education agency providing school social work services.
A person who meets the requirements for the position of school social worker and who is employed as an administrator or supervisor.
A university faculty person involved in school social work instruction or supervision.
A person eligible for Active Membership may become an Affiliate Member if retired or unemployed. Affiliate Members shall have all the rights of Active Members.
A professional person working in an agency which provides services to children. Additional persons, if they perform similar functions to school social work and are authorized within their state to do so, may be Associate Members. Associates do not have voting rights and cannot hold office, but will enjoy all other benefits of membership.
Would you like to also register for the SSWAA Leadership/Legislative Conference in Washington DC July 18 – 21, 2010?
No
Yes
Would you like to also register for the 14th Annual National School Social Work Conference March 30 - April 2, 2011 in Myrtle Beach, SC?
No
Yes
If yes, you will need to fill out this form electonically and mail a copy to the address below. Download SSWAA CONFERENCE FORM .
Please Mail your completed form to:SSWAA
Fax: 847-658-8223 (include purchase order if paying by PO) iasswck@aol.com
Conference:
Pre Conference Only
Pre Conference & Conference
Conference
One Day Only
HALF Day Only
Keynote Meal Only
One Day Only Attending on:
Wednesday
Thursday
Friday
Saturday
(Optional)
If you are attending for ONE DAY ONLY please select the day you would like to attend from above.
Keynote Meal? (Add $40)
No
Yes
(If not attending the Conference and would like to attend the Keynote Meal then please select Yes. Meal is included in Full Conference Registration.
Please note: If you are registering after March 7, 2011 a late fee of $35 will be added to the total.
If you have questions, Please email us at contact@sswaa.org .
NEW MEMBER BENEFIT: SSWAA members may
subscribe to the School Social Work Journal, Published by the
Illinois School Social Work Association, at a reduced
subscription rate of $20, a $10 Savings. www.iassw.org/journal.htm
