WSPA Membership Application

WSPA Membership Application
Name*

First NameLast Name
Student or 1st year Post DocECP (2-5 years post doctoral degree)Full Member (6+ years post-doc)Retired
New MemberReturning WSPA Member
Yes, I am joining today at an eventNo
What event are you attending today?
Welcome!

If you are a new member signing up today at our event, you are elligable for a $50 discount on your membership dues for the first year of being a WSPA Member. To ensure this discount is applied, use the code below when prompted on the check out page.

Once you submit this form you will be redirected to payment.

Your discount code is: NEWMEMBER50
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Academic/teaching roleArmed forces medical centerCommunity mental healthIn-patient settingMedical center / healthcare systemPrison or correctional facilityPrivate practiceSchool districtUniversity counseling centerVACurrent studentNot employedRetiredOther
Highest Degree Held or In Process*
Year Graduated from Doctoral Psychology Program*
If you are a student, please enter your expected graduation year
University (Doctoral Degree)*
If you are a student, please enter your current university
Have you attained board certification in psychology (ABPP)?*
Are you licensed as a psychologist?*
License Type*
Primary State of Licensure*
License Number*
Are you licensed in Washington State?*
WA License Number*
PSYPACT*
PSYPACT (APIT Number)*
If licensed in additional states, please select
To select multiple: on Windows, hold down the Ctrl key; on a Mac, hold down the Command key
Internal Demographic Questions

The questions in the following three sections (Contact & Professional Information, Demographics, & Disaster Relief Network) are for internal WSPA use only, and will not be shared.
All of the following questions are optional (please select "prefer not to say" if you do not wish to share this information). WSPA is committed to equity and inclusion, so your willingness to answer helps us determine how to best serve all our members, including members of marginalized communities both in our state generally and within psychology specifically.
Asian & South AsianBlack or African-AmericanLatinx or HispanicMENA (Middle East & North Africa)Native American or Alaska NativeNative Hawaiian or Other Pacific IslanderWhitePrefer not to sayPrefer to self-describe
FemaleMaleCisgenderTransgenderGenderqueerNon-binary/third gender/agenderTwo-SpiritPrefer not to sayPrefer to self-describe
He/him/hisShe/her/hersThey/their/theirsPrefer not to sayPrefer to self-describe
AsexualBisexualGayLesbianQueerStraight or heterosexualPrefer not to sayPrefer to self-describe
YesNo
Please enter Full Name of the WSPA Member who referred you:*
Welcome!

If you were reffered by a current WSPA Member, you are elligable for a $50 discount on your membership dues for the first year of being a NEW WSPA Member! To ensure this discount is applied, use the code below when prompted on the check out page.

Once you submit this form you will be redirected to payment.

Your discount code is: NEWMEMBER50
When you click Submit, you will be redirected to a Zeffy payment page to process your membership dues. You may pay by credit card, ACH, or check.
Should be Empty:

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WSPA Membership Application

Welcome!

Internal Demographic Questions

Welcome!