National Consortium for Physical Education and Recreation for Individuals with Disabilities (NCPERID)

Online Membership Application Form

Two steps are required to process your online membership application form. The first step is to send us your personal information. The second step is to make your secure online payment.

Step 1: Send us your personal information

Name
First Name:      Last Name:      Middle Initial:

Business or Work Address
Place of Business:
Department:
Street Address:
CIty:      State:      Zip:
Phone:      Email:

Resident Address
Street Address:
City:      State:      Zip:
Phone:

Primary Area of Professional Interest
     Specify if "Other":

Membership Category and Fee

Level of Current Employment (check all that apply)
College/University Public School State Education Agency
Private Agency Community Agency Hospital/Residential
Retired Student (name of current school: )

Education
Highest degree earned:      (specify if "other": )
For current students - degree you are pursuing: (specify if "other": )

For Current Students
Highest degree earned:      (specify if "other": )

Committee Preference (check all that apply):

Membership     Legislative     Awards     Newsletter