National Association of Christians in Special Education (NACSPED) Membership/Conference Application

Please print out this form and send it to: NACSPED P.O. Box 7415 Redlands, CA 92375 Be sure to include your check for application/registration fees made out to NACSPED. Click to close form after printing

______________________________ Name ______________________________ Home Address ______________________________ City, State, Zip ______________________________ Home Phone ______________________________ email address (please write clearly) Gender M F ______________________________ Denomination ______________________________ Ethnicity Which of the following best describes you? _____Special Education Teacher          _____Mild/Moderate _____Moderate/Severe          _____Other (please specify) __________ _____Parent of child with a disability _____Involved in ministry to persons with disability _____Person without professional training in disability, but with interest in experience with persons with disability (eg. business person) _____Other professional (please specify)__________ Credentials held ____________________________________________________________ ____________________________________________________________ For how many years have you been involved with persons with disability? _____ What areas of interest might you have related to special education or persons with disability? ____________________________________________________________ ____________________________________________________________ Highest degree earned ______________________________ Current educational status _____completed education _____full time student _____part time student Of which professional organizations are you a member? ____________________________________________________________ Are you interested in writing for a NACSPED newsletter? _____Yes _____No Are you interested in presenting at a NACSPED conference? _____Yes _____No Would you be interested in receiving a NACSPED newsletter sent to your email address? _____Yes _____No Where did you find out about the organization/conference? ____________________________________________________________ ____________________________________________________________ Membership rates - includes membership in NACSPED and the 2007 conference (select one) _____Regular member 75$ _____Student member 50$ _____Pastoral member 50$ Please complete this application and forward with your check made out to NACSPED for membership/conference registration to:

NACSPED P.O. Box 7415 Redlands, CA 92375