New Member Application

To apply for membership to the New York State Chapter, please complete the form below.

Below the form, please follow directions on how to pay the $20 annual membership fee via PayPal or check.

Once the application and funds are received, your application will be reviewed immediately, you will be notified promptly whether your application is approved, and, if so, within about a week, you will receive a letter, certificate, and email welcoming you to the group.

[Note: If you join between January 1st and June 30th, your membership will be effective for that calendar year. If you join after June 30th, your membership will be effective for that calendar year and the next calendar year. You will receive an email reminder when it is time for you to renew your membership.]

Membership Form

Salutation
Mr.Ms.Mrs.Dr.
Name *
Professional Certification/Degree
Agency/Company
Title
Field/Scope of Practice
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Email *
Phone *
Fax
Referred By
Today's Date

Verification

Please enter any two digits *Example: 12
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There are two ways to pay:

By PayPal:

By check:
Make check payable to: APSAC-NY
Mail check to:
c/o Minerva DeLeon
Vincent J. Fontana Center for Child Protection, New York Foundling
690 Avenue of the Americas, 14 Floor
New York, NY 10011