NJAPA Membership Application New Member Renewal

 Last Name First Name

 Address

 City County Zip Code

 E-Mail Address Home Phone Fax

 Sponsoring NJAPA Member

Enrolled in MEPAP Part I or II Instructor Name

Student discount $5.00 if enrolled in Basic or Advanced Activity Course

 Applying For Please Check if this is a Change from Last Year

Active Membership ($40 per year) 3 Years for $100

 Facility Name Job Title

 Address

 City County Zip Code

 E-Mail Address Work Phone Fax

 Type of Facility Long Term Day Care Residential Sub Acute Assisted Living
Retirement Senior Center Other

Associate Membership ($30 per year) 3 Years for $75

Retired Activity Professional Volunteer Student, School

Not Presently Employed       CNA Other

Please make check payable to N.J.A.P.A. and return to

Lisa Williams, ADC, CALA
NJAPA Membership Chair
3057 Cedarville Road
Millville, NJ 08332