TFA Individual Membership

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

Level of Education:

Ph.D MS/MA BS/BA AS/AA HS

Treatment Settings You Have Worked In (check as many as apply):

Group Home
Treatment Foster Care
Home Based Care
Day Treatment
Institution
School
Emergency Care
Other

Please explain your connection to the Teaching-Family Model:

I am an administrator in a TFA member agency I am a practitioner in a TFA member agency I am an administrator in a social services capacity I am a practitioner in a social services capacity I am interested in the Model but not currently involved in care Other

I believe I have technical proficiency in these areas (please list all):

Membership Type:

General Member - Individual (at a TFA Member Agency) = $30.00 General Member - Couple (at a TFA Member Agency) = $40.00 Supportive Member (not affiliated with a TFA Agency) = $60.00

Please indicate payment type:

Check/Money Order Credit Card Bill Me

If paying by credit card, enter your credit card number in the space provided below.

If paying by credit card, enter your credit card expiration date in the space provided below.