Wisconsin Association for Health, Physical Education, Recreation, and Dance (WAHPERD)

Membership Form

I. General Information
From: Month Year To: Month Year
Membership Type (Select One): Current New Renewal of Expired Membership

II. Contact Information
Last Name: First Name:
Street:
County: City: State: Zip:
Home Phone: Work Phone:
E-mail Address:

III. Students Only
School Attending:
Year (Select One): Freshman Sophomore Junior Senior Graduate 

IV. Primary Area of Interest (Select One)
Health - H General - G Physical Education - P Student - S
Sports & Athletics - A Recreation - R  Dance - D  
V. District and Membership Type (Select One of Each)

TYPE OF MEMBERSHIP
SE – Southeast District - CESA District 1

Lifetime ($400)
SC – South Central District - CESA District 2 Professional ($45)
SW – Southwest District - CESA Districts 3 & 4 Associate ($45)
C – Central District - CESA District 5 Student ($20)
E – Eastern District - CESA Districts 6 & 7 Retired ($15)
NE – Northeast District - CESA Districts 8 & 9 Contributing ($50)
NW – Northwest District - CESA Districts 10, 11, & 12 JRFH/Hoops Coordinator ($22.50)

Print this form and send by mail (with payment) to:

WAHPERD
24 Mitchell Hall 
1725 State Street
La Crosse, WI 54601-3788 

Make Checks Payable to: WAHPERD

OFFICE USE ONLY
EXP. DATE
Date Rec'd
CK#
Amt. PD		 __________
__________
__________
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