Illiniois Recreation Therapy Association

Join ILRTA

Member Information

Name:
Title:
Agency:
Agency Address:
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County:
Work Phone:

Home Address:
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Home Phone:
Email Address:
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CERTIFICATION

ATRA membership? Yes or No

Are you currently certified? Yes or No

If certified, by whom?:

INTEREST AREA AND SERVICE

Please check your area(s) of interest:

Please check the way(s) you would be willing to serve ILRTA:

Committee	Committee Chair
Board Member	Writing articles for the Newsletter
Assisting with the ILRTA Conference	Presenting at the ILRTA Conference

Office Use Only

Method of Payment:

( ) Check # __________________ ( ) Money Order ______________

Date Received: _______________ Amount Paid: ________________

Date Recorded:_______________

You may complete this form online and print it out. Send the completed form and payment ($30 professional or $15 student) to:

ILRTA
Sr. Sandra Salois, OSF
1311 Franciscan Way
Joliet, IL 60435
salois1311@comcast.net