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MEMBERSHIP APPLICATION ___New
Membership ___Reinstate
___Renewal
Address Information
First
Name____________________M.I.___Last
Name_________________
Mailing
Address__________________________________________________
City___________________ State____Zip
Code______Parish_____________
Office Phone (____) ______ Home Phone
(____) _______Fax (____) _____
Personal
E-Mail______________________Business
E-Mail_______________
Place of
Employment__________________________________
University(if a
student)_____________________________
Membership
Dues Membership in LCA
means that you will abide by LCA's Bylaws and other governing
documents, as well as the ACA's Code of Ethics, and are qualified
for the membership category selected. LCA Membership
(Please select the dues category for which you are
qualified.)
( ) $50.00 Professional Persons who hold a master’s degree or higher in counseling or a closely related field from a college or university that was accredited when the degree was awarded by one of the regional accrediting bodies. Must hold a membership affiliation with at least one division.
( ) $50.00 Regular Persons whose interests and activities are consistent with those of the Association but are not qualified for Professional membership. Must hold membership affiliation with at least one division.
( ) $30.00 Retired Individuals who have previously been Professional members, but who are now retired from from the counseling profession. Must hold membership affiliation with one division.
( ) $30.00 Student/Counselor Intern Persons who have verified that they are enrolled at least half time as degree seeking students in a counseling program in a regionally accredited institution; or an individual under supervision and not having received licensure. A Counselor intern must be registered with the LPC Board. Must hold membership affiliation with at least one division.
Division Membership Dues
Must join at least one division. Please check the appropriate membership type.
Louisiana School Counselor Association
(___) Prof/Reg/Retired $10.00 (___ ) Student $ 5.00
Louisiana
Association for Counselor Education and Supervision
(___) Prof/Reg /Retired $10.00 (___) Student $ 5.00
Louisiana Career Development Association
(___) Prof/Reg/Retired $ 5.00 (___) Student $ 2.00 Louisiana
Association of Marriage and Family Counselors
(___) Prof/Reg $ 10.00 (___) Student/Retired $
5.00 Louisiana Association for Spiritual,
Religious, and Ethical Values in Counseling
(___) Prof/Reg/Retired $10.00 (___) Student $ 5.00 Louisiana
College Counseling Association
-(___)
Prof/Reg/Retired $ 5.00 (___) Student $ 5.00 Louisiana
Association of Addiction and Offender Counselors
(___) Prof/Reg/Retired $ 5.00 (___) Student $ 3.00 Louisiana
Association for Multi-Cultural Counseling and
Development
(___) Prof/Reg/Retired $10.00 (___)
Student $ 5.00
Louisiana Mental Health
Counselors Association (___) Prof/Reg/Retired
$12.00 (___) Student $ 6.00 Association for Gay, Lesbian,
& Bisexual Issues in Counseling in Louisiana
(___) Prof/Reg/Retired $ 5.00 (___) Student $ 5.00
Affiliate Membership Dues
Must join at least one division. Please check the appropriate membership type.
Louisiana Counselors for Social Justice
(___) Prof./Reg./Retired/Student $5.00
Voluntary Contributions (Optional, but a great
way to get involved.) Research Trust Fund $__________
Legislative Trust Fund $___________ Scholarship Trust Fund $
_______ Legislative Action Fund $ _________
Include me in Blast Emails ____Yes
____No Email address______________
Membership Dues
Totals
| LCA Membership |
$ |
| Division(s) Membership
|
|
| Contributions |
|
| Total Amount
Remitted |
|
. Payment Method
(___)Check or money order payable to
LCA enclosed.
VISA (
_)
Master Card (__) Account
Number________________
Expiration Date______ V-code______
Authorized
Signature_______________________________________________
Mail Registration Form with check
payable to LCA or FAX with credit card information completed to
318-868-3341. Direct questions to:
Diane Austin, Executive
Director Louisiana Counseling Association 353 Leo
Shreveport, Louisiana 71105
1-888-522-6362 (No calls after 9:00
P.M.) FAX: 318.868.3341
Email: lca@shreve.net
www.lacounseling.org
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