2008 HLABA Registration and Membership Form

Phone: 402-331-0219

Fax: 402-331-0219

Address: 5007 Hamilton St.

Conference dates are October 9-10, 2008.

Conference Registration includes membership in HLABA through October 2009 and any BCBA and APA CE fees.

Last Name: ________________________________________

First Name: ­­­­­­­­­­­­­­________________________________________

Affiliation: ­­­­­­­­­­­­­­­­­­­________________________________________

Address: __________________________________________

City: _____________________________________________

State/Zip Code: ____________________________________

Home Phone: ______________________________________

Work Phone: _______________________________________

Fax Phone: ________________________________________

E-Mail: ___________________________________________

BCBA or BCABA Number: __________________________

___ 01 Administrator                     ___ 07 School Teacher

___ 02 Consultant/Trainer            ___ 08 Student

___ 03 Psychologist                      ___ 09 Professor/Academic

___ 04 Therapist                           ___ 10 Researcher

___ 05 Behavior Analyst               ___ 11 Speech/Language

___ 06 Parent                               ___ 12 Guardian

___ 13 Other:_______________________________________

___ 01 Full Member                                      

___ 02 Affiliate Member                              

___ 03 Student Member                   

Requirements for Membership Categories:

Full Member- Must hold at least a masters degree in experimental or applied behavior analysis (ABA), be a Board Certified Behavior Analyst, have made contributions to the field of applied behavior analysis (e.g., professional publications), or hold a full time professional position that includes teaching, research and/or practice in ABA.

Affiliate Member- Anyone who has an interest in Applied Behavior Analysis but does not meet the requirements of a Full Member.

Student Member- Anyone who has an interest in Applied Behavior Analysis and is a student on at least a half-time basis.  Student applications must be accompanied by an endorsement from a Full Member certifying the applicant’s student status or by other documentation certifying such.

Most Recent Degree:_________________________________

Year Received: _____________________________________

Conferring Institution: _______________________________

   I, ________________________________________________

   certify that _________________________________________

   is a full-time student at _______________________________

  __________________________________________________

    Faculty/Full Member/Affiliate Member Sign & Date:

Pre-conference Workshops (Oct. 9):

    #1 Dr. Iwata. Functional Analysis (AM)                                     $95*

    #2 Dr. Jon Bailey. Ethics for Behavior Analysts (PM)               $95*

Conference Registration/Membership (Oct. 10):

(includes lunch and snacks at the conference and CEs):

    Full Members                                                                            $80*

    Affiliate Members                                                                      $50*

    Student Members                                                                     $30*

*Workshop and conference registrations received on or before September 1, 2008 may deduct $10.00 from the registration fees listed above.

 ___ 01 Yes

 ___ 02 No

 __________ Pre-conference Workshop: Brian Iwata

 _________   Pre-conference Workshop: Jon Bailey

 _________   Conference Registration/Membership Fee

 _________   Donation

  _________ Total

 Please make checks payable to HLABA

   HLABA

   c/o Anney Fahrenholz

   5007 Hamilton St.

   Omaha, NE   68132

Membership, conference and workshop registration can be emailed to info@hlaba.org.

Payment online is available through Paypal at their site.  See our payment button on the Online Payment Option page.

Convention registration is required for all presenters/attendees for Paper Addresses, Symposia, Panel Discussions, and Exhibits.  Registration is not required for invited presentations and workshop presenters.  The fees are $95 for the preconference workshops (each), $80 Full Members, $50 Affiliate, and $30 Student, with a $10 discount for registrations received by September 1, 2008.