Please detach and retain for your records.
$125 Dues for the July 2020 – June 2021 fiscal year.
Dues are prorated for members joining
after July 2020.
❏
Check here if you wish to contribute $78 to ACSA’s Political Action
Committee.
Contributions to support ACSA's political activities are not tax deductible.
ACSA retains sole discretion over use of member political contributions.
Dues may be deductible as business expenses. ACSA estimates that the
non-deductible portion of dues allocable to lobbying is 13.3 percent.
❏ Check (full payment only)
❏ Payroll deduction*
Signature
(required for payroll deduction)
✽ I agree that my dues will be deducted by my payroll office. This
authorization shall be in effect until revoked by written notice from
myself or ACSA. I consent to the adjustment of such deduction to
reflect any change in the dues of which the payroll office may be
advised by the organization.
❏ MasterCard/Visa (full payment only)
Card Number Exp. Date
Signature (required for credit card charge) Date
A change of employment designation to administrative or supervisory will
require a change to Regular membership.
Student members do not have voting privileges, and are not eligible to
serve as ACSA officers, directors, or committee members, nor are they
eligible for Professional Legal Services. Qualifying members may
remain in the Student category a maximum of four years. Beyond
that, a change in membership type and dues will result.
Educational administration program enrollment at an accredited California Higher
Education Institution.
Referred by (Please print one name only)
First Name M.I.
Last Name
Position/Title
Last Four Digits of Social Security Number
District
School
Address
City State ZIP
Work Phone Extension
Work Email Address
Personal Email Address (Required)
❏
Check here if you do not wish to receive ACSA email at your work email
Address
City State ZIP
Home Phone Cell Phone
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Opt-in to receive text messages from ACSA.
Preferred Mailing Address
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Home
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Work
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Check here if you wish to view ACSA publications online only.
Date credential expected: _______________________________
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2020-2021 dues
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home
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payment options
limitations
Please call ACSA’s Member Services
Department at 650.692.4300 or
800.608.ACSA (2272)
Fax 650.437.9189
Email: memberservices@acsa.org
the path to
success
in educational
administration
begins at ACSA
ACSA offers special Student membership rates to
individuals who are enrolled in any education-related
graduate program leading to an administrative credential
at an accredited California institute of higher education.
(Individuals enrolled in coursework who are
designated as management or supervisory qualify for
Regular membership only.)
After completion of coursework, members securing
management or supervisory positions are elevated to
Regular membership with full benefits, including Member
Assistance and Legal Support Services.
not yet an administrator,
but completed your
coursework?
Associate membership is the category for you. Please call
ACSA at 800.608.ACSA (2272) or visit www.acsa.org for
more information.
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questions?
The information requested below will
remain confidential and will be used
for ACSA purposes only and will not
be sold to vendors or any third parties.
year of birth
__________________ ❏ Decline to State
gender orientation
❏ Male ❏ Female ❏ LGBT
ethnicity
❏ American Indian or
Alaska Native
❏ Chinese
❏ Japanese
❏ Korean
❏ Vietnamese
❏ Asian Indian
❏ Laotian
❏ Cambodian
❏ Other Asian
❏ Hawaiian
❏ Guamanian
❏ Samoan
❏ Other Pacific Islander
❏ Filipino
❏ Hispanic or Latino
❏ African American, not
of Hispanic origin
❏ White, not of
Hispanic origin
❏ Decline to State
education level
❏ Master’s Degree
❏ Doctorate
❏ Other
social media
❏ Facebook
❏ Instagram
❏ Twitter handle: __________________________________
SRC: _______________
2020-2021 STUDENT MEMBERSHIP APPLICATION
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