NSTY Membership Form

 

                       YEAR: 2009

Name_____________________________________________________   Spouse_______________

             Last                                        First                             Middle

Address: _____________________________________________________________

 

City:_____________________________  State:___________________  Zip:__________________

 

Home Phone: (_____)_________________ Work Phone: (____)___________________________

 

Fax: (_______)_______________________

 

E-mail:___________________________________________________

 

Birthday: _________/__________            TOY State represented: ___________  Year ______

                   Month              Day

Teaching Content Area/ Grade Level:_________________________________________________

 

Annual conferences attended: please circle the state/year in which you attended conferences.

 

NE  CA  AZ  NJ   TX  OR  MN  MO  LA  KS  TN  WA  KY  NV  IL  OH  HI   AZ  AR  NM  VA  NV  DE  PA  GU  WY  MO AK

80    81   83   84    85   86    87     88     89   90   91    92    93    94  95   96   97   98   99     00    01    02    03   04   05    06     07   08

 

Membership Categories:

                ______Active                                                                      $30.00 dues               NEW, REDUCED DUES!!!!!

                ______Retired                                                                    $15.00 dues                                                         

                ______New TOYs                                                              $15.00 dues

                ______Lifetime                                                                  No dues

 

Membership Dues enclosed (from above list)             $_____________

Scholarship Donations (optional):                                                

                Kay Battista Scholarship Donation                               $_____________

                NSTOY Family Award Scholarship Donation:          $_____________

NSTOY Endowment Fund (optional):                           $_____________

General Fund Donation (optional):

                For_________________________                                               $_____________

                Unspecified Use                                                                  $_____________

                                                                                  TOTAL             $_____________

                                                                               

Please make check payable to NSTOY and mail it along with this form to:

 

Carol Strickland; NSTOY; c/o National Teachers Hall of Fame; ESU Campus Box 4017; 1200 Commercial;
Emporia KS 66801

 

For Office Use Only:  Date Received _____/_______         Check #_________            Check Amount $____________

 

                                Membership card sent _____/______/20___