Individual Member Form Essential Info First Name * Last Name * Email Address * Contact Info Address Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal If you would like to leave your private mailing address type it here. It will not be shown in the the directory. Phone Number * Fax Number Website/URL http(s)://example.com or http(s)://www.example.com Social Accounts Facebook Twitter Google + Linkedin Pinterest About You * Best describes yourself or business. Which category/categories best describe(s) you (check as many as apply): * Administrator (Please clarify using comments below) Artist- Drama Artist- Poetry/Creative Writing Artist- Architecture/Design Artist- Expressive Arts Artist- Storytelling Artist- Visual Arts Artist- Other (Please clarify using comments below) Community Member/Advocate Counseling Professional- Licensed Clinical Social Worker Counseling Professional- Licensed Marriage and Family Therapist Counseling Professional- Psychologist Counseling Professional- Psychiatrist Counseling Professional- Other (Please clarify using comments below) Creative Arts Therapist- Art Creative Arts Therapist- Dance/Movement Creative Arts Therapist- Drama Creative Arts Therapist- Expressive Arts Creative Arts Therapist- Music Creative Arts Therapist- Other (Please clarify using comments below) Educator/Researcher (Please clarify using comments below) Healthcare Professional- Activities Director/Coordinator Healthcare Professional- Child Life Specialist Healthcare Professional- Nurse Healthcare Professional- Occupational Therapist Healthcare Professional- Physical Therapist Healthcare Professional- Physician Healthcare Professional- Recreational Therapist Healthcare Professional- Social Worker Healthcare Professional- Speech Therapist Healthcare Professional- Other (Please clarify using comments below) Student (Please clarify using comments below) Other Which category/categories best describe(s) you (check as many as apply): To select multiple entries hold control key down & select with mouse right click. Use this space to clarify the category/categories you chose above or any additional information: Arts for Your Profile Photo * Drop a file here or click to upload Choose File Maximum upload size: 2.1MB A profile picture is required, this can be your profile picture or business logo.When uploading a new photo: 1.) Upload new photo 2.) Uncheck the old photo 3.) Then click on Submit button Lookup
