Learning Forward Kansas Membership Application

Print this application, after completing, mail it with your check or purchase order # to the address at the bottom of this page.
Welcome to Learning Forward Kansas!

___$50 AGENCY MEMBERSHIP (Service centers, interlocals, higher education departments, or district central offices.) Membership includes:

• one copy of newsletter (agency may be photo copied)
• member rate for conference registrations (for certified and classified agency staff, not assigned to an individual school)

___$25 FOR EACH BUILDING MEMBERSHIP ... in combination with agency membership only and submitted with the Agency (District) membership (Individual buildings with separate street addresses such as high school, middle school, or grade school.) Agency members may add additional buildings to their membership for $25 per building if submitted with agency membership. Maximum of $250 per agency for 10 buildings or more. (If more than 10 buildings are listed, no additional charges will be incurred beyond $250) Please complete a membership application for each building. Membership includes:

• one copy of newsletter for each building (may be photo copied)
• member rate for conference registrations (building staff, certified and classified)

___$50 BUILDING MEMBERSHIP (for a building joining separately) Membership includes:

• one copy of newsletter (building may be photo copied)
• member rate for conference registrations for certified and classified building staff

___$25 INDIVIDUAL MEMBERSHIP (A membership for one individual.) Membership includes:

• one copy of newsletter
• member rate for conference registrations

___$0 FIRST YEAR TEACHER (A membership for one individual.) Membership includes:

• one copy of newsletter
• member rate for conference registrations

___$0 PRE-SERVICE STUDENT TEACHER (A membership for one individual.) Membership includes:

• one copy of newsletter
• member rate for conference registrations

Name ___________________________________________________

Title/Position _____________________________________________

Name of District/Agency/Building _____________________________

Day Phone _______________________________________________

Evening Phone ____________________________________________

Mailing Address ___________________________________________

City __________________________________Zip _______________

E-Mail Address ___________________________________________

- I belong to Learning Forward: YES NO        - Is this a renewal of your Learning Forward Kansas membership? YES NO

- New Member? YES NO             - If a new member, I was referred by _____________________________

Mail completed applications to: Tom Jerome, Learning Forward Kansas Treasurer, Box 616, Eudora, KS 66025

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The Learning Forward Kansas membership year begins October 1st and ends September 30th.