Membership Form

MABS Membership Form

To join MABS, simply fill out this form, press submit, and make a payment. Data submitted is listed in the MABS Providers List unless otherwise specified in your submission.

You may also print a membership form and mail the form and payment to: 

The Mid-Atlantic Biofeedback Society
c/o Bea Haskins, Executive Director
217 E. Middle St.
Hanover, PA 17331

Included in the Providers List:
Membership - Check one: 
Membership Level:

Name (Last, First):

Credentials:

Business Name:

Business Address:

City:

State:

Zip:

Phone:

Email:

Website URL:

 

The following information is for our records only and will not appear in your listing on the website:

Mailing Address (if different from above):


City:

State:

Zip:

Current Licensure (type and state):

Current Certification (if BCIA, please provide your certification #):

Interventions Employed (check all that apply):

Other (if selected above):