Organization Name, if applicable
Street City:
State: Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Montana Nebraska Nevada New Brunswick New Hampshire Missouri New Jersey New Mexico New York Newfoundland/Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Outside the US & Canada Zip County, if from Florida Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Dade De Soto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Monroe Nassau Okaloosa Okeechobee Orange Osceloa Palm Beach Pasco Pinellas Polk Putnam St. Johns St. Lucie Santa Rosa Sarasota Seminole Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington
Work Telephone: Home Telephone:
Fax E-Mail:
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DO NOT PUBLISH THE FOLLOWING INFORMATION IN THE FAIMH DIRECTORY
Address | Home Phone | Work Phone | FAX | E-mail |

	$25.00	Individual Membership - FAIMH only Florida Association for Infant Mental Health Individual Membership - FAIMH only (Excludes Infant Mental Health Journal &World Ass'n. membership)
	$5.00	FAIMH: Child Educator Membership Florida Child Care Workers, Educators, Parent Volunteers, etc.    Occupation:    Employed by:
	Free	Student Membership - FAIMH only - w/o journal Full-time Students w/copy of student ID & email address

Please check which FAIMH Chapter you would be located near or affiliated with!

	Broward Infant Mental Health Chapter		North Central Florida IMH Chapter (Gainesville area)
	Capital Area Infant Mental Health Chapter		North Florida Infant Mental Health Chapter
	Central Florida Infant Mental Health Chapter		Palm Beach County Early Childhood
	Early Childhood Council of Hillsborough County (Tampa area)		Escambia County Chapter of Infant Mental Health
	Emerald Coast IMH Chapter (Bay, Holmes, Washington, Calhoun, Gulf, Jackson Counties)		Early Childhood Mental Health Committee of Pinellas/Pasco Counties
	Great Beginnings - Okaloosa Walton Alliance for Emotional Stability in Early Childhood		Suncoast Chapter of the Florida Infant Mental Health
	Infant Mental Health Vision Council		Santa Rosa Chapter of Infant Mental Health
	Manatee Infant Mental Health Chapter		Tri-County Association for Infant Mental Health (Polk, Hardee, Highlands)
	Miami Infant Mental Health Chapter of FAIMH		Volusia/Flagler IMH Chapter
	Naples