EIPA New Member Application

We invite all providers (agencies and those individuals contracting directly with the county) of early intervention services birth through five who are interested and committed to promoting the best possible future for children with special needs and their families to join EIPA.

If you are interested in joining EIPA, we invite you to attend a regional meeting. Please review EIPA’s event calendar for your local regional meeting date-location and/or complete this application.

Once you complete the membership application, your information will be reviewed for membership eligibility. Upon approval by association leadership, you will receive a instructions for payment and access to your members-only account portal.

Who referred you to EIPA?

Agency Name

Agency Website

http://

Primary Contact Name

First Name

Last Name

Primary Contact Email

Primary Contact Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Contact Phone

(###)

###

####

Secondary Contact Name

First Name

Last Name

Secondary Contact Email

Secondary Contact Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Contact Phone

(###)

###

####

County/Region(s) Served

If unsure, please see our regional map on our member web page.

Number Served

(0-3)

(3-5)

Please select the appropriate level for your organization's Dues Structure