You
are invited to join
AGATE
– or renew your
membership
(Please print)
Name
___________________________________________________________________________________________________________________
Address
________________________________________________________________________________________________________________
City
_____________________________________________County
_____________________________________State
___________ Zip _________
Phone ( ) ______________E-mail
_________________________________________________________________
_______
New membership
_______
Renewal
Affiliation
- check all that
apply:
___ 1. Administrator
____ 7. Parent
____2. District Gifted Coordinator
____8. Home-schooled
____3. Teacher
____9. Student
____4. Teacher of gifted
____10. Organization representative
____5. Psychologist / Psychiatrist
____11. Private School
____6. Counselor
____12. University / College
School district:
____________________________________________________________________________________
University / College:
________________________________________________________________________________
Organization / Chapter / Affiliate:
______________________________________________________________________
Level of Membership
:
check one (all
memberships are tax deductible)
_____One year individual /
professional membership: $40.00
_____Two year individual /
professional membership $75.00
_____One year parent membership:
$25.00
_____Add $10 for a one-year joint National
Association for Gifted Children (NAGC) membership
which includes four issues
Parenting
for High
Potential
magazine: $35.00
_____One year student membership:
$10.00 (ID required)
_____One year
institutional/organization membership Includes 10
issues of
GEMS of
AGATE
$150.00
_____Lifetime individual membership
$350.00
Amount enclosed: __________
Send completed form and check
(payable to AGATE) to:
JoAnn Meaker
6081 Walworth Road
Ontario, NY 14519
jomeaker@yahoo.com
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