Member Information

First Name:                                                               M.I.                        Last Name:                                                                        

Organization/Affiliation:                                                                                                                                                                    

Address:                                                                                                                                                                                               

City:                                                                                                          State:                            Zip:                                                

Email:                                                                                                      Home Phone:                                                                    

Work/cell phone:                                                                                  Fax:                                                                                      

Please indicate which you are:  (a) Student                        (b) Faculty                      (c) Practitioner        _______

As a member of the Midwest Organization I agree to abide by the National Organization for Human Services (NOHS) Ethical Standards of Human Service Professionals.

Signed:_____________________________                     Date:____________________________

Six month membership fees from October 1 – March 31:

Faculty               $10

                                                               Practitioners       $10

Student                 $5

Checks should be made payable to: MWOHS

Membership Application forms and payment should be mailed to:

                                                Denise K. Sommers, EdD, LCPC

                                                University of Illinois at Springfield

                                                Dept of Human Svcs/Social Svcs Admin

                                                One University Plaza

                                                BRK 335; Mail Stop: BRK 332

                                                Springfield, IL 62703

(217) 206-6908

dsomm2@uis.edu

Please direct any questions regarding membership to Denise Sommers (see above)