Kentucky Association for Gifted Education
Membership Form

Please print and fill out the form below and return, with your payment, to KAGE, PO Box 9610, Bowling Green, KY 42102-9610. If you have any questions please contact the KAGE office at 270.745.4301 or kage@wku.edu.

Name:____________________________________________

Address:____________________________________

City:____________________________State:______Zip Code:__________

School District:________________________

County of Residence:___________________

KAGE Chapter: ________________________

Preferred phone:__________________________ This is home___ work___.

Email address:_________________________________

Would you like to be placed on the KAGE LISTSERV? __ yes __ no

CLASSIFICATION(S):
_____ Parent _____ Teacher _____ Resource Teacher _____ Gifted Coordinator _____ Counselor _____ Administrator _____ Resource Teacher _____ Other______________

TYPE OF MEMBERSHIP: __New __ Renewal

Annual membership is $30 per household. The NAGC Parent Associate membership (enables you to receive four issues of Parenting for High Potential and access to all resources on NAGC's website at www.nagc.org) is an additional $10.

KAGE FOUNDATION
KAGE members are encouraged to include a contribution to the KAGE Foundation when initiating or renewing their KAGE memberships. The KAGE Foundation provides scholarship assistance for gifted students attending summer programs offered by Kentucky universities. Foundation contributions are tax-deductible. If you are including a contribution please fill in the amount here: $________ Check Number________

_____ $30 KAGE membership ____$10 NAGC parent associate _____ KAGE Foundation donation ______TOTAL ENCLOSED


THANK YOU FOR YOUR SUPPORT OF KAGE!

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