CoPGTP Membership Application

    IMPORTANT: This form can not be saved. Review the form first to make sure you have everything you need before starting. (You can download and print the form out for reference.)

    Please fill out the sections below and then click the "Submit Information" button at the bottom. Please note that all fields are required unless otherwise noted.

    General Information:

    Date of Application:

    Applicant Organization/Agency/Institution Name:

    Training Program Name (if applicable):

    Department or Division (if applicable):

    Mailing Address:

    City:

    State:

    Zip Code:

    Country:

    Web Site for Program (if applicable):

    Primary Geropsychologist, Training Director, or Primary Contact Information:

    First Name:

    Last Name:

    Email of Primary Geropsychologist or Training Director:

    Note: Please indicate whether you want to be added to the Council email listserv:YesNo

    Phone Number of Primary Geropsychologist or Training Director:

    Fax Number of Primary Geropsychologist or Training Director:

    Training Contacts:

    Please list names of all Geropsychologists who provide training within your program and indicate whether they want to be added to the Council email listserv:

    1. First Name:

    Last Name:

    Email Address:

    Add to email listserv: YesNo

    2. First Name:

    Last Name:

    Email Address:

    Add to email listserv: YesNo

    3. First Name:

    Last Name:

    Email Address:

    Add to email listserv: YesNo

    Level(s) at which Training is Provided by Your Organization (check all that apply)

    Stage Training:

    American Psychological Association (APA) / Canadian Psychological Association (CPA)

    Accreditation (check one):

    Curriculum Vitae (CV) for Primary or "lead" Geropsychologist for your program:

    Please attach the CV for the Primary or “lead” Geropsychologist for your program. We may ask for CVs for other individuals as the application is reviewed but only 1 CV should be submitted at this point.

    Training Program Components:

    Provide below a brief narrative describing:

    1) The experiential professional training your program or organization has offered in previous 3 years, including professional supervision, case consultation, and experiential workshops (i.e., those emphasizing active learning of skills)

    2) The didactic training offerings your organization has offered in the previous 3 years, including courses, lectures, workshops, seminars, and related didactic activities. In the narrative, describe the training experience and the competencies trained


    (Please see attached list of professional geropsychology competencies as defined by Pikes Peak Model for Training in Professional Geropsychology).

    Certification:

    CoPGTP is not an accrediting agency. Programs that would like to include their membership in written materials may list their programs as "CoPGTP member," but not as "CoPGTP Accredited" or "CoPGTP Approved." CoPGTP membership indicates that a program meets all membership criteria and conforms to CoPGTP policies.

    Programs are reviewed for adherence to membership criteria every three years.

    Electronic Typed Signature of Training Director (or Primary Geropsychologist):