Membership Application
( PLEASE PRINT AND SEND BY MAIL)

Memberships may only be made in the name of an individial, NOT an agency, program, school or center.

Your dues payment includes membership in NAEYC, as well as membership in the following:

LOCAL:  ROCHESTER AEYC #052
STATE:  NEW YORK STATE AEYC

Date: _________________

PLEASE CHECK ONE ONLY:

(   ) $95.00 Comprehensive
(   ) $55.00 Regular
(   ) $35.00 Student

CHECK ONE:       (   ) New Member          (   ) Renewal

Name: _____________________________________________________________

Home Address: _____________________________________________________

City: _______________________________          State:______          Zip: _______

Work Phone #: ____________________          Home Phone #: ________________

E-mail Address: _____________________________________________________

Place of Employment: ________________________________________________

Position: ___________________________________________________________

Student ID: ____________________________________________    (If applicable)

College/University Name or CDA Instructor: ______________________________

___________________________________________________________________

PLEASE MAKE CHECKS PAYABLE TO: NAEYC
Mail check and this form to:
NAEYC
P.O. Box 97156
Washington, D.C. 20090-7156

Thank You!