Membership Form

Alabama Therapeutic Foster Care Providers Association
Affiliate Application

You may join online or print this form and fax

FYI: When you hit Submit, you may receive a pop-up message asking if you would like to continue or cancel. Choose continue if you would like to complete your online registration.

Name Title

Organization Name

Address

City ST Zip

Phone Fax Email

Designation (use one of the following)

Abbreviation	Designation Title	Abbreviation	Designation Title
FP	Foster Parent	LPC	Lic. Prof. Couns.
SW	Social Worker	OC	Other Clinician
S	Student	Other	All Others

Annual Dues

Corporate Sponsor: $250.00	Foster Parent: $25.00
Clinician: $50.00	Student: $10.00

Total Due*:

Please send only checks, money orders, or purchase orders.

If you register online and do not receive an email acknowledgement within 24 hours, please email

Send payment to: (Please print a copy of this form for your records)

ATFCPA

C/O P.O. Box 70245

Montgomery, AL 36107

You may also fax this form to:

(334) 269-6314

For other information, contact:

(334) 220-6242

Email: ATFCPA

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