The Utah Gerontological Society
Membership Form
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Member Information: |
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Name: |
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Association: |
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Address: |
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City/State/Zip: |
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Work Tel: |
Home Tel: |
Other Tel: |
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Fax Tel: |
E-mail Address: |
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Professional Information (Check all that apply): |
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o Advocate o Educator o Government Employee o Home Healtho Legal o Long Term Care o Medical o Mental Healtho Non-Profit Employee o Nutrition/Dietician o Private Practiceo Social Worker o Senior Citizen o Studento Other: ________________________________________ |
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The Utah Gerontology Society has several standing committees. Please check any you are interested in: |
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o Conference o Awards and Grants o Finance o Membershipo Nominations and Elections o Publications and Public Relationso Education / mini-conferences o Research and Practiceo Health Promotion o Senior Centers & Nutrition Services (SCANS)Suggestions: _________________________________________ |
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Would you like to receive occasional mailings from related agencies and organizations? o Yes! Please make my name available for other aging related mailings o No! Please only send me Utah Gerontological Society mailings |
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General Member: o $40.00 pr/year Senior (65+) Member: o $25.00 pr/year Student Member: o $25.00 pr/year Additional SCANS Membership (Optional):Includes specific mailing and training events regarding Senior Centers & Nutrition Services o Addtn’l $5.00 pr/year |
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Total Enclosed: $____________ |
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Make Checks Payable To: Utah Gerontological Society Mail completed form with membership fee to: P.O. Box 521-740 SLC, UT 84152-1740 |