Indiana ASCD Member Application

Thank you for choosing to become a member of Indiana ASCD!  Please complete the following information requests and submit your membership fee to start enjoying the benefit of membership.  Your first and last name and at least one mailing address and phone number must be submitted to process your membership request.  If you prefer, a hard copy can be downloaded, completed and submitted along with your membership fee to Indiana ASCD.  If you have any questions, please contact Jamyce Curtis Banks at (317) 536-3327 or indianaascd@gmail.com. For a complete list of member benefits, please visit the Member Benefits page by clicking here. To email this application to a colleague, click here.

Applying For	New Membership Renewing Current Membersip       - Indiana ASCD Member #:
Your First Name*
Your Middle Name or Initial
Your Last Name*
Mailing Address*
City*
State*	select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
County of Residence (Indiana Residents Only)
Zip*
Home Phone	( ) -
Mobile Phone	( ) -
Personal Email*
District / Company Name*
School Name*
Work Address
City
State	select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Work Phone	( ) - ext.
Fax Number	( ) -
Work Email
If more than one mailing address was provided, which do you prefer to be the primary address?
Home        Work
If more than one phone number was provided, which do you prefer to be the primary phone number?
Home        Work
If more than one email address was provided, which do you prefer to be the primary email address?
Personal       Work
In what format do you prefer receiving future issues of the Indiana ASCD Report?
Electronic Copy Only        Print Copy Only
Although responses to requests below are optional, we ask that you complete or update the information. Responses will be used only to report aggregated data as required by ASCD and/or to assist us in targeting information to be included in our newsletters.  Please select the response that best describes your current situation.
Race / Ethnicity	select... Asian or Pacific Islander Black, Non-Hispanic American Indian or Alaskan Native Hispanic or Latino White, Non-Hispanic Multi-Racial Other
Years of Experience in the Education Profession	select... 0 - 4 5 - 15 16 - 25 26 - 30 31+
Job Title / Description	select... Building-level Administrator Building-Level Specialist (librarian, guidance, etc.) District-level Administrator Classroom Teacher (preK-12) Consultant Department Chairperson Indiana Service Center or Department of Education Employee Education Industry Vendor Professor, Instructor, Dean (Post-Secondary) Retired School Board Member Other
Content Area	select... Administration All Subjects – Elementary Career / Vocational Education (i.e. Business, FACS, IT, T.V.)" Educational Leadership English-Language Arts Guidance Librarian / Media Specialist Mathematics Music / Performing Arts PE / Health Reading Science Social Studies Special Education Teacher Education Visual Arts World Languages Other
Grade Level	select... All Grades Elementary High School Intermediate School Junior High / Middle School Post Secondary PreK Secondary Other
Are you a member of our parent affiliate, ASCD?	Yes No
Click Below to Submit Your Indiana ASCD Membership Information & Pay Your Membership Fees Online.
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