NEW PATHS - Individual Registration Form
Please fill out the Online Membership Form below for new registrations, renewals, or those who would like to rejoin.
After you click "submit" at the end of the form, you will have the opportunity to pay for your membership though PayPal back at the Membership page on the NEW PATHS website by clicking on the PayPal Payment button. You may also print out a PDF version of the application, found on the Membership page of the website, and choose PayPal or submit a check.
Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Preferred Contact Phone No. *
Your answer
Preferred Contact Email *
Your answer
Please select membership status: *
Membership type: *
Length of Membership: *
Chapter Affiliation:
Your answer
Membership renewed at Training Seminar? *
Membership renewed at Training Seminar? *
Please tell us about where you work
Job Title *
Your answer
State *
Your answer
Work Phone *
Your answer
Extension (if applicable)
Your answer
Agency Name *
Your answer
NOTE: Your $1000 group life insurance coverage begins with NEW PATH'S next premium payment.
Please complete the information below regarding the group life insurance.
Name of Beneficiary *
Your answer
Relationship *
Your answer
Address (if different than your own above) *
Your answer
Date of Birth of Registrant (for insurance policy purposes only) *
MM
/
DD
/
YYYY
All member information is kept strictly confidential
Were you referred to NEW PATHS by someone? *
If yes, who referred you?
Your answer
Which chapter do they belong to?
Your answer
Submit
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