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First Name (include middle initial or part of first name) *

Last Name *

Email Address (used by the membership website to send password reminders, renewal notifications - NOT DISPLAYED PUBLICLY) *

Username (lowercase alphanumeric) *

Password (enter twice to confirm) *

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Additional Info

Do you want to be listed in the ONLINE directory? *
Yes, to everyone (Publicly Visible) No, only to logged in members (Privately Visible)

Show Email Address (If you've opted to be listed in the ONLINE directory you can still hide your email from the public) *
Yes, to everyone No, only to logged in members

Degree(s) to be displayed next to name on site directories and membership lists (if opted in)

Primary Directory Listing

Professional Title

Organization Name

Street Address

Street Address Line 2

City

State

Zip

Phone - Primary contact #, include 'x' for extensions (ie 215-875-4300 x 4321)

Fax

Email Address (This will be displayed with primary listing)

Website

Secondary Directory Listing (optional)

Professional Title

Organization Name

Street Address

Street Address Line 2

City

State

Zip

Phone - Primary contact #, include 'x' for extensions (ie 215-875-4300 x 4321)

Fax

Email

Website

Private Contact Info (If you prefer to be contacted at a private address or number, please provide that info. Any address, phone, fax, or email-address supplied in this field is for internal use only and not displayed with your listing on the site or in the membership directory.)

Mailing List / ListServ Preferences

Constant Contact Mailing List Preference (SOS uses an e-mail marketing tool called Constant Contact to notify members and others of SOS programs and workshops. Do we have permission to add your name and email to the SOS Constant Contact mailing list?) *
yes, opt-in no, opt-out

ListServ (Please indicate whether you wish to be registered for the SOS List Serv) *
yes, opt-in no, opt-out

Background Information

Background (Have you ever been convicted of a crime which involves honesty, integrity, or improper/unlawful conduct with children or adults? Please explain.) *

Terms of Use & Privacy Policy (I have read and understand the Specialists of Schools Privacy/Use Policy, and understand that any contact information I elect to display in the specialists finder/directory are publicly available.)

Billing Method

Credit or debit card

Billing Address

Street Address *

City / Town *

State / Province *

Postal / Zip Code *

Country *

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