On-Line Membership Form

The information you give us will only be used by ATN for purposes of informing you about our organization.  Your information will not be given to others without your expressed permission.  However, if you’d like us to connect you with other families in your geographic area, please indicate that we have the permission to share your name and email (You can share your other contact information with individuals as they contact you.)   You can read our privacy policy <here>

1. *Name:
2. Address

   Street_ Address
   Address (cont.)
   City
   State/Province
   Zip/Postal Code
   Country

3. Phone
4. *Email

5. * Yahoogroups login

Tell us about yourself:

6. Are you currently parenting a child (children) with attachment or trauma issues?    Yes      No
7. If you are not, what areas (reasons) are you seeking support:
a. I’m a preadoptive parent
b. I’m an extended family member
c. I’m a professional interested in attachment & trauma
d. I’m an adult adoptee
e. Other:   
8. How many children are in your household?
9. What are their ages? (please note the children you’re concerned about)
10. What are your biggest concerns? (behaviors, symptoms and issues that you seek support for)

11.  Do you consider your child's issues to be:  Severe    Moderate  or     Mild ?

12.  I am currently a member of this ATN online support community:

  ATN_Parents

  ATNP_Teens

  Little Zebras

  Little Stripes

  Pre-Adopt

  Big Zebras

  Little Horses

  RAD Professionals

13. Do you want to be contacted about events in your area? 

Yes      No


14. I give permission to ATN to give my name and email (only) to other families in my area seeking peer support?

Yes      No

15.  I give permission to ATN to include my name, email and yahoo ID in an online directory that will be placed in the online support groups files (accessible by list serve members only, not the general public.) 

Yes      No

16.  How did you hear about the ATN & our online community?  

Membership Type

Please select the membership type and payment option you prefer.

  Individual Memberships -- $35/annually  <more details>

  Professional Memberships - <more details>

$125/ annually sole practitioner

$250/annually practice

$20/annually (associate member with in practices)

Payment Options
 

Pay via credit card through ATN Store – here
 

Call 240-357-7369 to place order via phone.
 

Fax printable form to 301-473-9399 with credit card information.
 

Mail check or money order with printable form to:
ATN
P.O. Box 164
Jefferson, MD 21755
 

If you are experiencing financial hardship and would like to apply for a scholarship, click here.
 

 

After submitting this form, please print out your submissions for your records.  Thanks.


If you have any questions, contact us at membership@attachmenttraumanetwork.com.