Membership
Application
Connect with us!
Regular membership is available to:
California employees in a district or other educational agency designated or functioning as:
n Management employees
n Members of the management team
n Administrators with regular part-time teaching responsibilities
n Confidential employees, classified or certificated supervisory employees
(No person shall be eligible for Regular Membership who is represented by an exclusive bargaining representative, except for certificated supervisory and classified
supervisory employees whose positions have previously been designated by the employer as management or who are functioning as management.)
Professors of Education
Employees of the California Department of Education (CDE) or
Commission on Teacher Credentialing (CTC)
Get connected to educational leaders across the state
through ACSA’s myriad social media offerings or visit
us at www.acsa.org
2021-2022
regular
n Free Professional Liability Insurance and $10,000 Accidental Death Insurance!
n Invaluable legal assistance for work-related concerns. Access to veteran administrators knowledgeable about the Educational Codes and your due process rights.
n Continued learning opportunities for brand new and seasoned leaders. Skills training on the latest trends and hot topics in education.
n Timely award-winning publications that keep you informed about issues and resources throughout the state and the nation.
n Professional connections with colleagues throughout the state. An established and growing network of leaders with savvy and practical advice for every situation.
n A strong lobbying voice for school administrators and timely electronic legislative alerts.
n Hot jobs delivered to you through weekly issues of EdCal. Jobs are also available right at your fingertips at www.acsa.org
n National and state awards and recognition.
n Exceptional member benefits that save you time and money.
Plus... You are eligible for membership in ACSAs national affiliates.
Here’s what's in it for you!
ASSOCIATION OF
CALIFORNIA SCHOOL
ADMINISTRATORS
Annual salary as of June 30, 2021 $ _______________
Dues calculation x.0090
ACSA dues amount (maximum $1,525) $ _______________
ACSA PAC* +$78.00
Total ACSA dues $ _______________
*Check here if you do not wish to contribute $78 to ACSAs Political Action Committee.
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
Opt-in to receive text messages from ACSA.
Preferred Mailing Address
Home
Work
Check here if you wish to view ACSA publications online only.
( )
ACSA’s Membership Recruitment Team provides assistance
to region leaders and region membership chairs in developing
goals and identifying non-members in districts within their
service areas. The Membership Recruitment Team also promotes
the value of ACSA membership to all administrators and to
those new and aspiring. They are available for presentations
on member benefits and services and are a tremendous
resource of information. To find out how you can contact
your local Membership Recruitment Team member, please call
the Member Services Department at 800.608.ACSA or email
memberservices@acsa.org.
Please detach and retain for your records.
( )
( )
2021-2022 dues
payment options
DISTRICT/COUNTY OFFICE PAYS
If choosing this option, send form to district for authorization and
payment. This section must be completed by district or county office.
Please indicate:
ACSA Dues (excluding $78 PAC) Affiliate Dues
District P.O. or check enclosed
Bill district monthly
Authorizing party (please print)
Phone number
Email Address
( )
your job classification
Free Professional Liability Insurance and
$10,000 Accidental Death Insurance
(Regular members only)
You are also eligible for all
member benefits including:
n
In-depth reporting and features through EdCal and
Leadership Magazine
n
Timely news and practical information from ACSA News online
at www.acsa.org
n
Reduced registration to the Leadership Summit.
n
Life, accident, disability and cancer insurances
n
Auto/homeowners and personal umbrella liability coverage
n
Discount purchasing
2021-2022 REGULAR MEMBERSHIP APPLICATION
CA Association of African American Superintendents/Administrators (CAAASA) ....$500 (Supt.)/$100 (Other Admin)
National Association of Elementary School Principals (NAESP) ...............................$235
National Association of Secondary School Principals (NASSP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$250
CA Assoc. of Asian & Pacific Islander Leaders in Education (CAAPLE) ..........................FREE
Check below to become a member in one of ACSAs official affiliates.
SELF PAY (select one)
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.
Three equal installments (Enclose first payment. Not offered after September 2021.)
MasterCard/Visa (full payment only) Check (full payment only)
Card Number Exp. Date
Signature (required for credit card charge) Date
Certificated management and supervisory
Certificated management & teacher
(dues based on admin salary)
Classified management and supervisory
Confidential as recognized under EERA
CDE or CTC (Associate Membership optional)
Professor of Education (Associate Membership optional)
Charter School Administrator
Other
Are you represented by an exclusive
bargaining representative?
Ye s No
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.
business
home
( )
Subtotal Affiliate Dues $
local
representation
For further details, call the ACSA Member Services
Department at 650.692.4300 or 800.608.ACSA(2272)
Fax 650.437.9189 • Email memberservices@acsa.org
Dues prorated for the number of months remaining in the school year for members joining after July 2021.
Referred By (please print one name only)
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.
You are immediately covered by:
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
ethnicity
year of birth
_____________________
Decline to State
gender
Male Female
Non-Binary Decline to State
orientation
LGBT+
education level
Master’s Degree Doctorate
Other
social media
Facebook Instagram
Twitter handle
__________________________________
SRC: _______________
click to sign
signature
click to edit
click to sign
signature
click to edit