Professional Member Form
Pay By Check

Professional Member Form
(Pay By Check)

Professional Members of AFHS-M, Inc. are Arts and Health Practitioners with varied experience, education, and training in using an art form (e.g. visual art, drama, dance and movement, music, expressive arts, etc.) to promote health and wellness at all stages of life for individuals, groups, and organizations. The information on this application will also serve as your database form for the Arts for Health Practitioner and Organization Plus Directory after it is reviewed and accepted. For your records, please make a copy of all entered information before submitting to AFHS-M, Inc.

PLEASE FILL OUT ALL REQUIRED FIELDS.

Essential Info

Please send check to this address and write invoice number on check in the memo section.

Arts For Health Sarasota-Manatee
7727A Holiday Drive
Sarasota, Fl. 34231
First and Last name.
Best describes yourself or business.
In the Location (address) field, if your location (address) is a private residence and wish not to have address listed in directory, then please just type in your city and zip.
If you would like to leave your private mailing address type it here. It will not be shown in the the directory.

Contact Info

http(s)://example.com or http(s)://www.example.com

Social Accounts

Integration Work

Your arts and health integration work.
Primary Art Form(s) used in Arts and Health Integration Work.
Select venues in which you performed Arts and Health work. To Select Multiple (Hold CRTL & Right Click)
For each experience of Art and Health integration work, please specify: your role, population and organization served, and dates. If you have been doing Arts and Health work for a number of years, please summarize the required information. (200 words, or less)
If you have done Arts and Health integration work with individuals outside of an organization, company, or community group, please summarize activity. (50 words or less)
Bulleted Sevice Items (60 words)
List five bullets points or less about yourself as an Arts and Health practitioner, and any other information you feel would be helpful to your description. (50 words, or less)

Licensed Therapist

CLICK HERE If you are a Licensed Therapist:
List credentials and affiliations.
Drop a file here or click to upload Choose File
Maximum upload size: 8.39MB
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
Sending