MICHIGAN THERAPEUTIC RECREATION ASSOCIATION
MEMBERSHIP APPLICATION

Name _______________________________ Title ________________________

Address 1 _________________________________________________________

City: _________________________________ State ______ Zip ___________

Preferred email of contact ____________________________________________

Address 2 (If student, permanent address; if professional, home address)
Address: ___________________________________________________________
City: _________________________________ State: ______ Zip: ____________

Phone (H) _________________________ Phone (W) _______________________

Do you wish to be contacted via email for MTRA announcements (i.e. meeting announcements, upcoming workshops) ___ Yes ___ No
Do you wish to have your membership letter and certificate sent via email ___ Yes ___ No

Check the Appropriate Blank:

____ Recreation Therapy Professional ($15.00)

• Voting member
• Certification # __________________
• Expiration Date _________________
• Are you a member of ATRA?
  ____ Yes ____ No

____ Supporting Member ($10.00)

• Nonvoting member

____ Student Member ($10.00)

• Nonvoting member. An individual enrolled in a Recreation Therapy education program

Please answer the following

1. Years of experience in TR
__ 0-3 __ 12-15
__ 4-7 __ 16-19
__ 8-11 __ 20 +

2. Primary Population:
______________________________

3. Organization/Agency:
_______________________________

Are you willing to be an intern supervisor?
___ Yes ___ No

Can MTRA place your facility name as an internship placement site
___ Yes ___ No

Complete this form and return to:
5751 Byron Center Ave, SW Suite U PMB# 103
Wyoming, MI 49519

*** Annual membership is from January to December of each calendar year. The information gathered on this form is for statistical purposes only and will remain confidential