AATH Membership Application Form

You may also download the AATH Membership Application Form and fax it to: 949-715-6931.

AATH
65 Enterprise
Aliso Viejo, CA 92656

If you have any questions about AATH or membership, please call us at: 888-747-AATH (2284) Toll Free or 949-715-4681 International.

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Member Information
First Name:		Prefix:
Last Name:		Middle:
Gender:	Male   Female	Suffix:
Address 1:		Address 2:
City:		State:	Select: -------------- AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code:		Country:
Company:		Title:

Phone Numbers
Work:		Extension:
Mobile:		Home:
		Fax:

Other Information
Email:		Website:
Referred By:		Profession:

Topic Categories (choose up to 3)
Humor and Health	Humor and Business	Humor and Family	Humor and Spirituality
Humor and Crisis	Humor and Therapy	Humor and Caregiving	Humor and Education
Humor and Happiness	Other

If you selected Other, please describe:

Speaker Professional Categories (choose up to 3)
Author	Allied Health Professionals	Education	Caring Clown
Mental Health Professional	Physician	Nurse	Clergy/Spiritual Support
Business/Corporate	Performer (magician, clown, musician, singer, comedian)	Other

If you selected Other, please describe:

Regular Membership
	1 year, $107 2 years, $197 - save $17! 3 years, $277 - save $44!
Gold Membership - Linked to personal website
	1 year, $157 2 years, $287 - save $27! 3 years, $407 - save $64!
Student Membership - Must be full-time
	1 year, $47
Senior Membership - Must be 65 or older
	1 year, $77
International Membership - Additional Postage
	$30 per year

		Preview Total Charges
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