The Association of Neuropsychology Students in Training

THE ASSOCIATION OF NEUROPSYCHOLOGY STUDENTS IN TRAINING

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AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 40 – NEUROPSYCHOLOGY

THE ASSOCIATION OF NEUROPSYCHOLOGY STUDENTS IN TRAINING

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THE SOCIETY FOR CLINICAL NEUROPSYCHOLOGY / APA DIVISION 40

INTEREST GROUP REPRESENTATIVE APPLICATION

Instructions:Please first read the Interest Group and Interest Group Representative Primer located on the ASNT website. Read the statement below and type your responses in the application form. By completing and turning in this form you agree to all responsibilities involved in acting as an ANST Interest Group Representative. After completing the form, email to the ANST account at as a Microsoft Word attachment. If you have difficulties using this form, contact ANST using the ANST email account.

CONTACT INFORMATION
INTEREST GROUP REPRESENTATIVE #1 / INTEREST GROUP REPRESENTATIVE #2
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
SUFFIX: / LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
SUFFIX:
PREFERRED EMAIL ADDRESS:
PREFERRED TELEPHONE NUMBER: ( ) - / PREFERRED EMAIL ADDRESS:
PREFERRED TELEPHONE NUMBER: ( ) -
YEAR IN PROGRAM:
ANTICIPATED GRADUATION DATE: / YEAR IN PROGRAM:
ANTICIPATED GRADUATION DATE:
PROGRAM & FACULTY SPONSOR
FACULTY SPONSOR NAME:
PREFERRED EMAIL ADDRESS:
PREFERRED TELEPHONE NUMBER: ( ) - / SCHOOL/UNIVERSITY:
PROGRAM:
MAIL ADDRESS LINE 1:
MAIL ADDRESS LINE 2:
CITY:
STATE:
ZIP CODE:
PROGRAM INFORMATION
PLEASE LIST THE NEUROPSYCHOLOGY COURSES OFFERED IN YOUR DOCTORAL PROGRAM, LISTING THE NUMBER OF CREDITS PER COURSE IN PARENTHESES:

PLEASE LIST THE NEUROPSYCHOLOGY PRACTICA OFFERED IN YOUR DOCTORAL PROGRAM, LISTING THE POPULATIONS AVAILABLE AT EACH PRACTICUM IN PARENTHESES:

PLEASE LIST THE NAME AND CONTACT INFORMATION OF AN ADMINISTRATOR IN YOUR PROGRAM THAT MAY BE CONTACTED TO VERIFY THE ABOVE INFORMATION:
INTEREST GROUP REPRESENTATIVE AGREEMENT

Please read each of the following statements and type your initials in the space provided to the left of each statement. There are spaces provided for up to two Interest GroupRepresentatives in case anInterest Grouphas moref than one representative. By initialing, you accept the position of ANST Interest GroupRepresentative and the duties and responsibilities of the position as outlined in the ANST Interest Groupand Interest GroupRepresentative Primer.

CR#1CR#2Statement

As an ANST Interest Group Representative, I have read and understood the

ANST Interest Group and Interest GroupRepresentative Primer and its contents.

I agree to abide by all duties and responsibilities outlined in the ANST

Interest Group and Interest GroupRepresentative Primer regarding the creation of an ANST Interest Group and maintenance of its active status. I understand that if I do not abide by these duties and responsibilities, ANST reserves the right to provide fair warning, followed by possible temporary deactivation of the Interest Group. If there are continued difficulties, I understand that ANST reserves the right to remove the Interest Group.

In this application process, if requested to provide additional

documentation by ANST I will do so in a timely and thorough manner.

I understand that this is a leadership position and that I am acting as a role

model for my Interest Group members.

I agree to keep in regular contact with the faculty sponsor to update him or

her regarding Interest Group issues.

If I have any questions regarding my position and/or its responsibilities, I

will contact ANST using the ANST email account.My most current contact

information is as listed above. If any of my contact information or my Interest Group’s representative changes, I will notify ANST.

NOTE: If you have any questions, concerns, or administrative requests (e.g., requests for materials, requests for correspondence, address changes, etc.) direct them to the ANST email at . ANST will channel your request to the appropriate person.

FACULTY SPONSOR AGREEMENT

Please read each of the following statements and type your initials in the space provided to the left of each statement. By doing so, you accept the position of ANST Interest Group Representative and the duties and responsibilities of the position as outlined in the ANST Interest Group and Interest Group Representative Application.

SponsorStatement

I agree to fulfill the role of Faculty Sponsor for this Interest Group. Should I no longer be able to fulfill this role, I will provide immediate notification tothe Interest Group representative(s) and, if necessary, assist in locating an appropriate replacement sponsor.

As Faculty Sponsor, I have read and understood the ANSTInterest Group

and Interest GroupRepresentative Application and its contents, including what is expected of an Interest Group, Interest Group Representative(s), and the faculty sponsor.

As Faculty Sponsor, I willmaintain regular contact with the Interest Group

Representative(s).

If I have any questions regarding my position and/or its responsibilities, I

will contact ANST using the ANST email account.My most current contact

information is as listed above. If any of my contact information changes, I will notify ANST.

Page 1 of 4 Revised: 08/28/2014