Application - Associate & Affiliate Members - CAIP - Canadian Association of Irlen Professionals

CANADIAN ASSOCIATION OF IRLEN PROFESSIONALS
REQUEST FOR ASSOCIATE & AFFILIATE MEMBERSHIP

* Indicates required field

Name *

First

Last

Address *

Address 2 *

City *

Province *

Postal Code *

Date *

Phone Number (Primary) *

Phone Number (Cell) *

Phone Number (Office) *

Email *

Check which statement best describes your situation *

Retired or inactive Clinic Director Inactive or uncertified Screener Retired or inactive Diagnostician PASS Screener

Complete the sections that describe you best *

Non-resident Supporting professional Parent of an Irlen client Irlen Client

Currently being serviced by: *

What is your profession? *

Child's name (optional) *

Associate and Affiliate membership fee: $25 per year

Submit