COLORADO SANDPLAY THERAPY ASSOCIATION

MEMBERSHIP FORM
Complete and mail form with payment

Date                                                               q NEW           q RENEW

 Name                                                                          Credential                                      

Mailing Address                                                                                                                       

City                                           State                            Zip Code                                         

If practice:  q private    q agency/institution (name)                                                              

Day Phone                                           Evening Phone                                                                 

Fax                                                      E-mail                                                                       

Check One

Professional Member Dues      q  $40      q  Two years $70                         

Student/Friend  Member Dues q  $25      q  Two years $40

Payment Method 

q Check:   Payable to CSTA 

q Credit Card:  q Visa  qMC  #                                                                            

Expiration Date:                                           

Signature:                                                                                                                   

Mail completed form with payment to:

Colorado Sandplay Therapy Association
P.O. Box 100295
Denver, CO  80250-0295