Name                : 
   (Type exactly as you would like to have it appear on your certificate)


   Position Title      : 

   Place of Employment : 


   Mailing Address
           Street      :  
           City        :   
           Province    : 
           Postal Code :   


   Telephone 
                  Work :  
                  Home :  
                  Fax  :  


   Academic Degrees 
   
   
	(Title)	               (Year)	             (School)
   
	(Title)	               (Year)	             (School)	
   
	(Title)	               (Year)	             (School)	


   What type of Health Care Agency are you employed with?
   


   Years in present position   Number of staff supervised  

   
   Areas you would like CASWHA to address:
 
      Professional Development      
      Clinical Supervision
      Program Management 
      Program Planning
      Social Work Policy Administxative/Budgeling
      Other areas:
      Clinical Standards (specify.) 
      Management Training (specify) 

   Language of Preference:

   When possible, CASWHA will attempt to print all formal documents m both French and English. 
   Please indicate m which langnage you would like to receive same:
   Enghsh      French


   Are you a former member of CASWHA? 
   Yes         No  

   If YES, please indicate year of most recent membership:   


   I will mail to the address below: 
   $125.00 (Full Membership)    
   $45.00 (Associate Membership)
 
   Please male cheques payable to CASWHA and mail to the Membership Chairperson, 
   whose address is listed below:

   Della Beattie, 
   Social Work Manager, 
   PsycHealth Centre,
   PZ413-771 Bannatyne Avenue, 
   Winnipeg, Man. 
   R3E 3N4