ACR Chicago Membership Application Form

  Personal Information

Name* Email*
Address*
City* State* Zip*
 
Phone* Fax
If Student: School Graduation Date



Please check all that apply:
  One Year Individual Full Membership Fee of $55.00
  One Year Individual Benefits Only Membership Fee of $30.00
  One Year Organizational Full Membership Fee of $110.00
  One Year Organizational Benefits Only Membership Fee of $60.00
  One Year Full-time Student Membership Fee of $10.00
 

Additional Tax Deductible Gift of:

  $250   $100   $50   Other $ 
This donation will be used to support Programming, online Practitioner Directory, and Website
  I want to be listed on the online Practitioner Directory. Please email or mail my personal username and password.

TOTAL

  $

 

I am:
a new member
a renewing member

I am a current member of ACR National


I would like to join the following (check all that apply):
Programming Committee
Membership Committee
Public Relations and Outreach Committee
Diversity and Equity Task Force
Conflict Resolution Day
Technology

To assist us in providing better Programming and Services for our members, we request that you take a moment and provide us with the following information:

I am an experienced dispute resolution professional and work primarily in the following areas:
Mediation Arbitration Training Other please specify
Other skills and experience
Corporate/Commercial and Tort Labor/Employment
Community Human Resources
Education Faith-Based
Court Social Services
Family/Divorce Restorative Justice
Other - please specify:

I am interested in Mentoring as a Mentor Mentee
Please note that requirements of the mentoring relationship are flexible and can be decided by the two members. Relationships can range from a few meetings to other activities..



Optional:
Gender Male Female                
Ethnic Background   African-American   Asian   Caucasian   Hispano/Latino Multiracial    
Age 18-24 years 25-34 years   35-44 years   45-54 years 55+ years    
Education (highest achieved) High school College   Masters   JD PhD Other
Professional background   Counseling   Human Resources Law   Teaching   Training Other