ASAHPERD Membership Application

Please fill out this form or print and return with payment to
ASAHPERD Membership
PO Box 369
Arley, AL 35541

Questions? Call 205-388-0304

 Member Information
*First Name:
*Last Name:
*Home Address:
*Home City, State:
*Home Zip:
*Home Phone:
*Interest Area 1:
Interest Area 2:
*School System:
Work Address:
Work City, State:
Work Zip:
Work Phone:
*Work County:
(determined by county of employment)
 Login Information
*Email: *Password
Membership Date Range 2/22/2019 - 2/22/2020 List my data in the membership directory
 Membership Category
Professional - Active HPERD or related employment$40
Aide - HPERD paraprofessional$25
Student - Full-time undergraduate or full-time graduate student major in HPERD or related field
Subject to verification; Not available for individuals currently employed in a full-time HPERD or related field
Jump Rope/Hoops for Heart - JRFH/HFH Coordinator and have completed event previous year
(ONE discounted membership per school)
Retired - Professional member for 10 years prior to retirement$25

 Payment Information
*Membership Category:
*Payment Method: Credit Card Mail
Card Number:
(enter without spaces)
Expiration Date (mmyy):
We accept Visa, MasterCard, and Discover.
Spam Prevention Code:   
Enter Spam Prevention Code:
* required field