SPR :: SECURE ONLINE MEMBERSHIP APPLICATION

If you want to pay by check or money order, then CLICK HERE to download a printable PDF version of this form. Print it, fill it out, and mail it to the address at the bottom of this page. You need Adobe's free Acrobat Reader program to open this PDF file.
Membership Status (check one):
Renewing Member (Please complete this form in full to assist us in updating our records.)
New Member
Membership Type (check one):
Regular Member, ONE YEAR, 01/01/2014 - 12/31/2014  $170
Student Member, ONE YEAR, 01/01/2014 - 12/31/2014   $75
     (Includes students and post-doctoral fellows.)
     Indicate Level of Study:
      Bachelor's  Master's  PhD  Post-Doc Fellow
     Expected Date of Completion:  (MM/YYYY)
Membership Information:
First Name:
Middle Name:
Last Name:
Highest Degree:

PhD MD ScD DrPH EdD JD MS MA MSW MPH MEd MPP

MPA BA/BS Other: 

Date of Degree:
Granting Institution:
Current Employment Information:
Career Level: (check one):
Student Post-Doctoral Fellow First Yr. Professional Early Career
Mid Career Senior Other  
Employer, Institution, Organization:
Position / Title:

Division / Department:

Is this an endowed position?: Yes No

Mailing Information:
Address:
 City: State / Province
Zip / Postal Code
Country

Telephone:
Fax:
Email Address:
Select preferred Prevention Science journal subscription delivery? Electronic Print
May we post your contact information in the SPR website membership directory? Yes No
May we distribute your contact information to other SPR Members? Yes No
Would you like to be included in the Early Career Preventionist Network (ECPN) listserv? Yes No
Would you like to be included in the Diversity Network Committee (DNC) listserv? Yes No
Would you like to be included in the International Task Force (ITF) listserv? Yes No
Gender (check one):
Male Female
Ethnicity (check one - optional*):
American Indian, Native American Spanish, Hispanic, Latino
Asian, Pacific Islander White, Caucasian, European
Black, African American Other
Disabled (optional*):
Yes No
*This optional information assists SPR in obtaining grants and awards.
Type of Organization (check one):
College or University For-profit organization
Government agency or organization Private Practice/Consultant
Non-profit research center not affiliated with a university Non-profit service agency
Other  
Occupational Type (check one):
Administrator Practitioner
Educator/Instructor Researcher
Policy Maker  
Current research populations of interest (check all that apply):
Infants Young Children
Elementary Adolescents
Adults Elderly
Current research content areas (check all that apply):
Academic Achievement Obesity
Alcohol Occupational Safety
Cancer Other Chronic and Disabling Condition
Cardiovascular Disease Other Health
Cognitive Development Other Infectious Disease
Crime Physical Development
Delinquency Physical Health
Diabetes Poverty and Economic Issues
Drugs Pregnancy
Family Violence Culture, Race, Ethnicity
Gender Differences Social/Emotional Development
HIV/AIDS Substance Use or Abuse
Infant/Child Health Tobacco
Unintended Injury Unemployment
Maternal Health Youth Violence
Mental Health Other (specify details in box below)
Areas of Special Interest (check all that apply):
Advocacy Infrastructure
Commercial International
Community Mobilization Training
Current Intervention Targets/Units of Interest (check all that apply):
Individuals Couples
Families Peer Group
Classroom Community Group
Entire Community State
Current Intervention Targets/Ethnicity (check all that apply):
American Indian, Native American Spanish, Hispanic, Latino
Asian, Pacific Islander White, Caucasian
Black, African American Other
Current Research Foci (check all that apply):
Developmental Psychopathology Neuroscience
Dissemination and Implementation Science Other Biological
Epidemiology Other Methodology
Etioloy Prevention Effectiveness
Genetics Preventive Efficacy
Large Scale Implementation
Meta-Analysis
Other (specify details in box below)
Prevention Activities at Your Institution
Is there an endowed chair in prevention at your current institution?
Yes No
Is there a formal training program in prevention at your current institution? (check all that apply)
Undergraduate Graduate
Post-Graduate No Program
Are there courses in prevention science offered at your current institution? (check all that apply)
Undergraduate Graduate
Post-Graduate No Program

Are you a member in other Prevention Science-related organizations?

Yes No (If Yes, please enter below.)

Are you willing to distribute information about SPR to colleagues or students at your institution?

Yes No  

2014 SPR Annual Giving Campaign

Check below if you wish to make an investment in the future of prevention research by contributing to the SPR 2014 Annunal Giving Campaign, which will support such SPR activities as: develop standards of replication, fund minority scholarships, promote science and advance policy.
No, Thanks   $25   $50   $100   Other  $

ECPN John B. Reid Early Career Award Fund

Check below if you wish to contribute to the ECPN John B. Reid Early Career Award Fund.
No, Thanks   $25   $50   $100   Other  $

     

 

Society for Prevention Research's Tax Identification Number is 13-3750819. SPR dues are not deductible as a charitable contribution for federal tax purposes, but may be deductible as a business expense. Contributions are deductible for federal income tax purposes to the extent provided by law. You may submit this form, with credit card payment, online using this secure form. To pay with check or money order, you may CLICK HERE to download a printable PDF version of this form. Print it, fill it out, and mail it to the address at the bottom of this page. You need Adobe's free Acrobat Reader program to open this PDF file.

Society for Prevention Research
11240 Waples Mill Road
Suite 200
Fairfax, VA 22030
P 703-934-4850
F 703-359-7562
Membership@preventionresearch.org