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MeAIMH Membership Application
Name: ___________________________________________________
Address 1: ___________________________________________________
Address 2: ___________________________________________________
City: ________________________ State: ____
ZIP: ____________
Daytime Phone: ____________________________________________
Profession/Position: ___________________________________________________
Membership Choice Dues Enclosed
Agency membership:
(5 copies of Newsletter and other publications, 10% discounts for any five staff member's at MeAIMH sponsored events)
 $150.00 $________
Individual membership:
(Individual copy of Newsletter and other publications, 10% discount at MeAIMH-sponsored events) 		$35.00 $________
Student membership:
(Same benefits as Individual: please provide name of agency or institution at which you are studying on a full-time or part-time basis) 		$20.00 $________
International membership:
(Same benefits as Individual plus membership in the World Association for Infant mental health and receipt of its quarterly journal)		 $155.00 $________

Donation:
(Because membership dues only partially offset expenses of the Association, donations in excess of dues are extremely valuable)

Thank You $________

Dues and donations are both tax-deductible.

Make check payable to MeAIMH
Membership year is October 1st - September 30th
Print and Mail to :

Debra Nugent Johnston
MeAIMH Executive Coordinator
592 Sawyer Road
Greene, ME 04236
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