Tennessee Recreation Therapy Association
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TRTA Membership Application
You may complete this form online, print it out, & mail it to TRTA

Name:

Title:

Agency:

Agency Address:

City:

State: Zip:

County:

Work Phone:

Home Address:

City:

State: Zip:

County:

Home Phone:

Email Address:
Do you prefer to receive your mail at home or work?
CERTIFICATION

Are you currently certified? Yes or No

If certified, by whom?:

Certification by: Date of Certification:

 

INTEREST AREA AND SERVICE

Please check your area(s) of interest:
Mental Health Substance Abuse Rehabilitation
Corrections Counseling Aging
Adolescents Community Development Disabled
Please check the way(s) you would be willing to serve ILRTA:
Committee Committee Chair
Board Member Writing articles for the Newsletter
Assisting with the TRTA Conference Presenting at the TRTA Conference
Office Use Only

Method of Payment:

( ) Check # __________________ ( ) Money Order ______________

Date Received: _______________ Amount Paid: ________________

Date Recorded:_______________

Send the completed form and a check in the amount of $10 to :

TRTA
Charles Gorecki, CTRS
1220 8th Avenue South
Nashville, TN 37203
 





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