Membership Application / Renewal

CHANNEL ISLANDS ASSOCIATION of DIABETES EDUCATORS
P O Box 2257 Atascadero, CA 93423 www.ci-ade.org

Federal Tax ID# 36-3641089

Date:______________________________ q Renewal q New

Yearly dues for CI-ADE are $35 (One year from date of renewal)

The chapter usually meets four times a year

!!!! Make check payable to "CI-ADE" !!!!

Please indicate appropriate membership status:

q Active Member $35: A healthcare professional providing direct diabetes education. This includes the registered nurse, registered dietitian, physician, physician assistant, pharmacist, podiatrist, psychosocial counselor, exercise physiologist, optometrist, and other members of the diabetes teaching team.
(NOTE: CI-ADE participates in the AADE Chapter Dues Collection Program. When you pay your national dues, the Chapter's $35 is sent to CI-ADE. There is also a $10 discount for paying this way.)

q Link from CI-ADE website $50: In addition to annual dues, this provides a link to www.ci-ade.org for referrals to your personal business and/or website. Please provide link information and any graphics you would like displayed.

NAME: _______________________________________________________________
DEGREE(S) ______________________ CDE? Y ____ N ____
MEMBER OF AADE NATIONAL? Y____ N _ AADE#________________
AREAS OF EXPERTISE: (ie, gestational, renal, etc.) ________________________________________________________________________________________________________________________________________________
EMAIL ADDRESS: _____________________________________________________
If no email then FAX #:
MAILING ADDRESS: ________________________________________________________
______________________________________________________________________
PHONE: WORK:_______________ HOME:____________ CELL: _____________
TITLE/OCCUPATION: __________________________________________________
COMPANY/EMPLOYER: ________________________________________________
NOTE: If you prefer your name and contact info is NOT listed in the roster which will
be distributed to members only, check here. DO NOT LIST:_______