If you are interested in becoming a Founding Member of the JBMTI Research Network, please print out the following form, complete it, and send it with your check for membership to:

LInda Hartling, Ph.D.
Jean Baker Miller Training Institute - WCW
Wellesley College
106 Central Street
Wellesley, MA 02481

Name: ________________________________________________________

Mailing Address: ______________________________________________________________

______________________________________________________________

Phone number: (W) ___________________________________

(H) ________________________________________

Fax number: ___________________________________

e-mail: __________________________________________

Please circle the appropriate code:

2 clinician/therapist

3 both (1 + 2 above)

4 student

5 other (specify) _________________

Research/Training/Clinical Interests: (Circle the numbers of all applicable items, up to five.)

Please provide a brief description of your research collaborations thus far (if applicable).

Please check any of the following areas in which you have experience:

Founding Membership Dues: $1 per $1000 of the member's annual income or whatever you choose to donate.

Please make your check payable to the JBMTI Research Network, and mail this form to:

Linda Hartling, Ph.D.
JBMTI - WCW
Wellesley College
106 Central Street
Wellesley, MA 02481

Lhartling@wellesley.edu

If you have any questions about the network, contact Network Coordinator, Mary Tantillo, Ph.D., R.N., C.S., by phone at (716) 275-0324 or by e-mail at tantillo@rochester.rr.com