Registration


Please fill out the form below. Fields marked with an asterisk* are required.

Please note: This is the Wisconsin version of EASy. If you are applying in another state, please be sure to select that state from the drop-down below.


Please use a personal email address (yahoo, gmail, etc.) as many agency email servers block emails from EASy.


Education (check all that apply)


Work Experience(s) with/related to infants, toddlers and their families*

Total number of years paid work experience with or on behalf of infants/toddlers and/or their families:


Reflective supervision/consultation:

Additional:


Documentation

You may attach a resume or curriculum vitae. This is recommended if you have more than 3 relevant paid work experiences.

File should be in .PDF, .DOC, .DOCX or .RTF format


Membership

mm/dd/yyyy

You must join or renew membership to WI-AIMH (or another infant mental health association) when submitting this preliminary application.


Endorsement Category*


Please review and verify all data before submitting!