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CHARTA
CHESAPEAKE AREA RECREATIONAL THERAPY ASSOCIATION
MEMBERSHIP APPLICATION

DATE:
NAME:
EMPLOYER:
MARYLAND .... DC .... VIRGINIA
 
MAILING ADDRESS:
CITY/STATE/ZIP:

IS THIS HOME OR WORK?
(ALL CORRESPONDENCE WILL BE MAILED THERE)

OFFICE PHONE:
HOME PHONE:
FAX:
E-MAIL ADDRESS:

 

MEMBERSHIP CATEGORIES:

PROFESSIONAL $20.00 Must be CTRS, include NCTRC #
ASSOCIATE $15.00 Employed in field, not a CTRS
SUPPORTING $10.00 Promoters of TR(non voting)
STUDENT $10.00 Name of school attending
ORGANIZATION $75.00 Groups interested in TR

Interested in being on a CHARTA committee?
Interested in starting a commitee?
Mark any from the list below:

 Membership
Legislative
Program
Other

 

Complete this form online and print it out and send it with
payment (check or money order) to:

CHARTA
Carrie Halupa
William Hill Manor
501 Dutchman's Lane
Easton, MD 21601