Membership

Membership Application

Please fill out the application and use your browser's print button to print it. Mail the form with your payment to the address below.

Check the box if SDGPS has permission to publish the information. If we do not, your information remains confidential and will not be printed in the Member Directory. SDGPS database is maintained for the Society's use only.

Name:		Degree:
Address:		Credential/Lic:
Address Line 2:		Certificate #:
City:
State:
Zip Code:
Home Phone:		E-Mail:
Work Phone:
Fax:

Referred to SDGPS by:

Are you a member of the American Group Psychotherapy Association?

Member Notes: If you would like to publicize your professional awards, presentations, accomplishments or other personal and professional news in the newsletter, please describe below:

Group Listing: Please complete the information below if you would like your group listed in the newsletter.

	Group 1	Group 2	Group 3
Day:
Time
Frequency:
Type of Group:

Annual Dues:          $30.00
Student Dues:         $15.00
Life Membership:     $450.00

Please enclose check with your application, payable to SDGPS.

Using your browser's print button, print the form and mail to:

SDGPS c/o Elizabeth S. Hammer
6735 Decanture Street
San Diego, CA 92120-2140