FADSA/NADSA Membership Application

FADSA membership fees INCLUDE the National Adult Day Services Association (NADSA) membership and will expire on December 31st. Remember, as per the by-laws: "Dues shall be assessed at the beginning of the fiscal year of the Association, January 1. Members joining for the first time after July 1, shall pay one-half the full fee. After this, the fee each year shall be paid in full."

To apply by mail: Fill in all boxes below,DO NOT CLICK ON "SEND MESSAGE" box, print page and mail with payment to: Florida Adult Day Services Association, 5200 NW 43rd Steet, #102 PMB-310, Gainesville, FL 32606

For assistance, call Alicia Schlindler at (305) 762-1469. Names placed in the "Authorized By" box will be considered as an actual signature.

To apply on-line with Credit Card Payment: On-Line Credit Card Payments Cannot be Accepted at This Time. We are sorry for any inconvenience!

A. Center Member - $210 Annual - Orgainizations licensed by the Florida Agency for Health Care Admin. to provide adult day care. (yes or no)

B. Individual Member - $ 160.00 - Persons interested in sporting adult day services in Florida. Individuals need not be currently affilitated with a licensed Florida Adult day care center. (yes or no)

C. Corporate Member - $355 Annual - Organization interested in supporting adult day services. Member organizations need not be affiliated with a licensed Florida adult day care center. (yes or no)

D. Web-site Link - $60.00 additional fee (yes or no)

E. Agency/Organization:

F. Name:

G. Title:

H. Mailing Address:

I. City:

J. State:

K. Zip:

L. Phone:

M. Fax:

N. E-mail:

O. Web-site Address:

P. County:

Q. Center License #:

R. Center Capacity:

S. For Profit or Non-Profit: (list which)

T. Authorizing Signature:

U. Total Amount Paid:

Comments: