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SIERRA GOLD ASSOCIATION OF SCHOOL PSYCHOLOGISTS 2009/2010 MEMBERSHIP APPLICATION ____New Member ____Renewing Member NAME: ___________________________________________________________ HOME ADDRESS: ____________________________________________________ HOME PHONE: ______________________________________________________ CELL PHONE: _______________________________________________________ SCHOOL DISTRICT/ COUNTY OFFICE: ______________________________________ JOB TITLE: _________________________________________________________ WORK NUMBER: _____________________________________________________ E-MAIL ADDRESS: ___________________________________________________ (Home address or email address will be used as address for newsletters and mailings unless otherwise specified on the application).

_________________________________________________________________ Please Provide the Following Information: ____Active Member ____Associate Member Degree: ____ MA

25.00 25.00

____ MS

____Student Member ____Retired Member ____ M.Ed. ____ Ph.D.

15.00 15.00

____ Ed.S.

____ (other) ______

Years of Practice: _____________________ CASP Member (not required): ____ Y ____ N st Memberships run from September 1 through August 31 ____________________________________________________________________________ Make checks payable to SGASP and mail to SGASP c/o Linda Wilson, 2480 Merrychase Drive, Cameron Park, CA 95682. We are sorry no purchase orders can be accepted at this time. If you have any questions regarding membership for SGASP, please e-mail any member of the board, Estella Marquez ([email protected]), Linda Wilson ([email protected]), Hannah Hargrave ([email protected]), George Rooks ([email protected]) and/or Lisa Laird ([email protected])

For SGASP use only: Date Received _____________________ Check No. _______________ Membership card sent ______________________ Card Number _______________________ Entered in Computer _______________________