RIAHPERD Application for Membership - Membership Year: September 01 - August 31

Name       Title 

Home Address   

City    State + Zip Code 

Telephone     Email 

Business Address    

City    State + Zip Code 

Telephone     Email 

Please check one:              Renewal     New Membership 

Membership Category:                    Most Appropriate Discipline:         Most Appropriate Employer:

            (Check one)                                              (Check one)                                          (Check one)

Professional $30.00                    Health Education                     School System

Lifetime $300.00                         Physical Education                  College/University

Retired $15.00                              Recreation                                Government Agency

Student* $15.00                           Dance                                        Hospital/Health Ctr. 

                                                                 Recreation Ctr.                       Dance Studio

                                                 Other     

*Please provide following information:                                                                                                        

Year of Graduation   From   (college/university)              

Major(s)    Other:      

 Mailing Preference:  (check one)         Home     Business                                                        

Return this form with a check or money order to: