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Membership Application Ohio Psychological Association MEMBERSHIP APPLICATION First Name: _________________________________ Last Name: ____________________________________ Degree: ___________________ Ohio License Number (if applicable): __________________ Ohio Date of Licensure (if applicable - MM/DD/YYYY): _____________________ Other State Licenses (if applicable): ___________________________________________ Date of Birth (MM/DD/YYYY): _____________________ Email Address (Online UserName): ___________________________________ Online Password : ______________________________________ (Minimum 8 characters, 1 upper case letter and 1 number or special character) Select Membership Category: Benefactor Members: Must be Licensed or Non-Licensed with Doctoral Degree to be eligible for these categories. Category Dues Description President’s Club members receive a $75 OPA promotional code, free Premium listing in the q President’s Club $750 Find-a-Psychologist Referral Program, special notation in quarterly OPA publications and on the OPA website, and are invited to attend the annual President’s Club dinner. Sustaining Members receive a $50 OPA Continuing Education promotional code, a free q Sustaining $450 Premium listing in the Find-a-Psychologist Referral Program, and special notation in quarterly OPA publications and on the OPA website. Full Members: Must be Licensed or Non-Licensed with Doctoral Degree to be eligible for these categories. Category Dues Description q Career Experience 7 + years $360 Licensed or Non-Licensed with Doctoral Degree and have 7+ years of career experience. q Career Experience 5 – 6 years $225 Licensed or Non-Licensed with Doctoral Degree and have 5-6 years of career experience. q Career Experience 1 – 4 years $150 Licensed or Non-Licensed with Doctoral Degree and have 1-4 years of career experience. q Career Experience under 1 year $100 Licensed or Non-Licensed with Doctoral Degree and have less than 1 year of career experience. $75 - Age 65 and Over and fully retired – A separate application is required for NEW members of this q Emeritus / Fully Retired $250 category. Please call OPA at 614.224.0034 for application. Affiliate Members: Ineligible to vote or hold office, and have limited participation on OPA listservs. Category Dues Description q Student $25 Middle School, High School, College Undergraduate and College Graduate Level Professional working in field of Psychology or Individual / Organization who wishes to support/ q Partner $50 advance the purpose of OPA and the field of psychology in Ohio. Discounts are available for individuals who are: not currently practicing or teaching in Ohio; not currently employed in the field of psychology; working 20 hours or less a week; or, currently undergoing financial hardship or special circumstances (based on IRS reported gross income). Contact the OPA Central Office at 614.224.0034 for more information. Please note, additional documentation is required. Contact Information: PERSONAL (HOME) CONTACT INFORMATION: PROFESSIONAL CONTACT INFORMATION: Street Address: Organization / Business Name: ________________________________________________________ ________________________________________________________ City, State Zip: Street Address: ________________________________________________________ ________________________________________________________ County: City, State Zip: ________________________________________________________ ________________________________________________________ Home Phone: County: ________________________________________________________ ________________________________________________________ Mobile Phone: Business Phone: Business Fax: ________________________________________________________ __________________________ __________________________ Website: May OPA Contact You Via: q Fax q Email ________________________________________________________ Preferred Mailing Address: q Home q Professional Demographic Information (Optional): Email Lists / Online Forums: Outreach Contributions: Gender: q Male q Female OPA provides numerous COMPLIMENTARY Contributions / donations to the following programs online forums and listservs to help members / activities may be made in conjunction with your Race / Ethnicity: membership dues payment. Please see the back page of stay connected. Select the list(s) you would q American Indian/Eskimo this application for instructions. q Appalachian like to subscribe to below: q Asian/Asian American q General Forum (OPA-LINK) - Subscribe OPA-PAC (Political Action Committee): q Black/African American to OPA’s open member forum to OPA-PAC supports state political activities q Hispanic/Latino/Latina network and discuss current issues in that impact psychologists and consumers by q Pacific Islander the field of psychology. (Affiliate members contributing to campaigns and candidates. q White are not eligible to participate on this list..) As an unincorporated political action q Bi/Multi-Racial q committee, contributions are not tax q Other News Flash (OPA-NEWS) - NO CHAT LIST Periodic news/announcements from deductible. NO CORPORATE CHECKS OR Professional Setting: OPA Central Office. CORPORATE CREDIT CARDS can be accepted q Academic for payment of your OPA-PAC donation. q Forensics (OPA-FORENSICS) - OPA'S q Business Payment Options: q Hospital forum for forensic psychologists and issues related to the field of psychology. • Personal Check (payable to OPA-PAC q Military • Personal Credit Card q Private Practice q Early Career Psychologist (OPA-EARLY) - • Donations can be made in one lump sum q Public Sector OPA’s forum for recently licensed or in 4 equal monthly installments. q Retired individuals to discuss early career issues. Salary Range: q LGBT (OPA-LGBT) - Subscribe to OPA Project FAIR q $0 - $19,000 discussion on lesbian, gay, bisexual, and (Focused Advocacy Insurance Reform): q $20,000 - $39,999 transgender issues pertaining to the OPA Project FAIR was founded in 1997 to q $40,000 - $59,999 field of psychology. address the mounting concerns psychologists q $60,000 - $79,999 have with managed care and insurance q q $80,000 - $99,999 Neuropsychology (OPA-NEURO) - OPA’s company problems. Contributions to this q $100,000 - $124,999 forum for neuropsychologists and issues fund are tax-deductible. related to the field of psychology. q $125,000 - $149,999 Payment Options: q $150,000 + q Prescriptive Privileges (OPA-RxP) - • Personal or Corporate Check (payable to Forum for individuals to discuss issues OPA-FAIR) Affiliation Information: relevant to advocating for prescriptive • Personal or Corporate Credit Card privileges for psychologists in Ohio. • Donations can be made in one lump sum Are you a member of.... (Check all that apply.) or in 4 equal monthly installments q Small College (OPA-SM-COL) - Forum q American Psychological Association to encourage dialogue and facilitate If yes, which APA divisions? The Foundation for Psychology in Ohio: collaboration among small college The Foundation is a non-profit, charitable _________________________________ psychology faculty in Ohio. ________________________________ organization that supports educational q Student (OPA-STUDENT) - Subscribe programs, scholarships, Science Day prizes, REGIONAL ORGANIZATIONS: to this open forum to network research and other programs that benefit q Akron (AAPP) and discuss current student/new the science and practice of psychology. q Central Ohio (COPA) psychologist issues in psychology. Contributions are tax deductible. q Cincinnati (CAPP) q Cleveland (CPA) Payment Options: q Dayton (DAPA) • Personal or Corporate Check (payable to The Foundation for Psychology in Ohio) q Toledo (TAAPP) GRASSROOTS ADVOCACY: • Personal or Corporate Credit Card OTHER PSYCHOLOGICAL GROUPS: q Are you interested in helping to • Bequests, Insurance Policies, or Real q Ohio School Psychologists Association promote psychology’s legislative and Estate (call OPA for more information) (OSPA) regulatory agenda by receiving and • Donations can be made in one lump sum responding to timely advocacy alerts? or in 4 equal monthly installments q Ohio Women in Psychology (OWP) q Ohio Psychiatric Physicians Association Deductibility: Dues payments, contributions or gifts to the Ohio Psychological Association are not q Asian American Psychological tax deductible as charitable contributions for tax MEDIA RESOURCE GUIDE: purposes. They may be deductible as ordinary Association (AAPA) and necessary business expenses subject to the q Association of Black Psychologists q Are you willing to be contacted by restrictions imposed as a result of lobbying activities. OPA estimates that for the Association’s fiscal year (ABPsi) media regarding issues in psychology? Those who select to participate will 9/1/15 to 8/31/16, 20% of dues were allocated to q lobbying activities and are non-deductible; OPA Natl Latino Psychological Association be contacted for detailed information estimates that for the Association’s fiscal year 9/1/16 q Society of Indian Psychologists (SIP) about your media preferences. (Students to 8/31/17, 20% of dues will be allocated to lobbying are not eligible to participate.) expenditures and are non-deductible. Gifts to the q Other ____________________________ foundation and OPA-FAIR are tax deductible. Areas of Competency / Specialty / Focus: Online Referral Program: Practice Orientation: Treatment & Practice Areas: (Select ALL that apply) Consumers can search anonymously 24 hours (Select ALL that apply) q ADHD/ADD q Leadership Development a day 7 days a week at www.ohpsych.org q Acceptance
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