First Name:                 

Middle Initial:     

Last Name:                 

Agency/Program Name:                 

Position/Title:

Work Address:        Street Address:   

                            City:     State:     Zip:

                            County where program is operated:

Home Address :      Street Address:   

                            City:     State:     Zip:

Work Phone Number:     Work Fax Number:

Home Phone Number:     Website:

Work Email Address:

Home Email Address:

How many sites does your agency operate?

How many employees does your agency employ?

How many school age children are served each year by your agency?

What grades are served by your agency?

Do you operate a middle school program?  select one yes no  

Where is/are your program(s) housed? (check all that apply)

    School Based       Center Based     Religious Institution Based    Community Based

    Home Based Group/Family Child Care        Other (please specify)

For Individuals, Are you a SAC Credentialed Professional?  select one Not an Individual Membership yes no

Does your program currently have a valid state license?  select one yes no

Does your program have a current program Accreditation?                 select one yes no

Type of Membership                        select one NYS SAC Credentialed Professional or Student ($30.00/year) Individual ($40.00/year) Single Program ($125.00/year) Small Multi-Site Agency - up to 5 program sites/locations ($250.00/year) Large Multi-Site Agency - over 5 sites/locations ($500.00/year)

Method of Payment                           select payment method I will mail a check to NYSSACC Online Credit Card Payment/PayPal

Is this a new membership or a renewal membership?              select one New Membership Renewal Memebership

After completing and submitting this form, If you are paying by check, please send your check for the appropriate amount to:

    NYSSACC

    Attn.: Membership Department

    230 Washington Ave. Ext.

    Albany, NY 12203

After you press submit below, you will be brought to the online payment page.