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Membership Application: July 1, thru June 30, 2011 School Year

First Name:
Last Name:
Email Address:
Password:	(5-10) characters
Re-Enter Password:	(5-10) characters
To verify your identity should you forget your password, select and answer a question:	Select a question What is your mothers maiden name? What is your favorite color? What was your first car? What was your first pets name? Who is your favorite actor/actress? What is your favorite movie? What city were you born in?
Answer:
Title:
District or Organization:
Please select the Agency or the Service Area in which your district is located:	Select a Service Area College or University Retired Law Firm Michigan Department of Education State Project/Grant Other State Agency Other ----------------------------------------- Allegan ISD Alpena-Montmorency-Alcona ESD Barry ISD Bay-Arenac ISD Berrien RESA Branch ISD C.O.O.R. ISD Calhoun ISD Charlevoix-Emmet ISD Cheb-Otsego-Presque Isle ESD Clare-Gladwin RESD Clinton County RESA Copper Country ISD Delta-Schoolcraft ISD Dickinson-Iron ISD Eastern Upper Peninsula ISD Eaton ISD Genesee ISD Gogebic-Ontonagon ISD Gratiot-Isabella RESD Hillsdale ISD Huron ISD Ingham ISD Ionia ISD Iosco RESA Jackson ISD Kalamazoo R.E.S.A. Kent ISD Lapeer ISD Lenawee ISD Lewis Cass ISD Livingston ESA Macomb ISD Manistee ISD Marquette-Alger RESA Mason-Lake ISD Mecosta-Osceola ISD Menominee ISD Midland County ESA Monroe ISD Montcalm Area ISD Muskegon Area ISD Newaygo County RESA Oakland Schools Oceana Intermediate School District Ottawa Area ISD Saginaw ISD Sanilac ISD Shiawassee Regional ESD St. Clair County RESA St. Joseph County ISD Traverse Bay Area ISD Tuscola ISD Van Buren ISD Washtenaw ISD Wayne RESA Wexford-Missaukee ISD
Address:
City:
State:
Zip Code:
Phone Number:	() - ext
Fax:	() -
Is this your first time joining MAASE?	Yes No
Are you a new administrator this year?	Yes No
Select One:	ISD Administrator LEA Administrator None/Other
Primary Affiliations:	MAISEA Michigan Association of Intermediate Special Education Administrator MALSEA Michigan Association of Local Special Education Administrators No Affiliation
National CASE member?	Yes No Click here to apply or renew Case Membership.
“Community of Practice Interest (check all that apply)	Supervisors of Low Incidence Programs (SLIP) Severe Emotionally Impaired Administrators Hearing Impaired Program Administrators Adjudicated Youth Program Administrators Early Childhood Program Administrators Planner/Monitor & Compliance Administrators
Current Position/Role (check all that apply)	ISD/ESA Director Planner/Monitor LEA Administrator "Center" Program Administrator University/College Instruction MDE/related State Department of Education Services Attorney Private Practice Consultant Other
Membership Dues:	See "About Membership" for definition. MAASE membership ($80.00) MAASE non-voting associate membership ($45.00)

Please Select One:

Classifications Aspiring Administrator Retired Related Field Other

Other: