Exit this survey Membership Form (NonConference) Question Title Please complete the following to apply for membership to CTABA. Question Title * 1. Please provide the following information: First Name: Last Name: Organization E-mail Address: Phone Number: Street Address: City: State: Zip Code: The membership types are described below: Professional Member: Must qualify in one of the following categories: Licensed as a Applied Behavior Analyst or Behavior Analyst in any state Full membership of ABAI or APBA Certified as a BCBA, BCBA-D, or BCaBA Licensed as a Professional in a field in which behavior analysis falls within the professional’s "Scope of Practice" NOTE: New Professional members must attach a copy of your vita and course records or a copy of your BACB certificate. Associate Member: Must qualify in one of the following categories: Student Member: This category is for any individual pursuing formaltraining in the discipline of behavior analysis services. Registered Behavior Technician: This category is for individuals who currently hold the RBT credential through the BACB. Parent: This category is for parents of children who are consumers of behavior analysis services. Direct Care with no formal qualifications: This category also includes direct services staff for individuals that spend the majority of their working time implementing behavior programs. These individuals must be actively supervised by a professional member. Sustaining: Members who are able to provide substantial financial support to CTABA. Question Title * 2. Are you applying for a new membership or renewing your membership? I am applying for a new membership. I am renewing my membership. Question Title * 3. Select the type of membership for which you wish to apply: Professional Student Member Registered Behavior Technician Parent Direct Care with no formal qualifications Sustaining Question Title * 4. If you are a applying for an Associate Membership as a Student, please indicate your program here: Question Title * 5. If you are applying for membership as a Professional Member, please upload either copy of your vita and course records or a copy of your BACB certificate. DOCX, DOC, JPG, GIF, JPEG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File If you are applying for membership as a Professional Member, please upload either copy of your vita and course records or a copy of your BACB certificate. Done