Membership Application

New Member or   Renewal

Last Name:

First Name:

Middle Name:

Title: Ed.D.   Ph.D.   Mr.   Ms.

Home Email:

Home Telephone:

Cell Phone:

Home Address:

City:

State:

Zip:

Birth month:

Birth day:

Which of the following best represents your racial or ethnic heritage? Choose all that apply. Asian/Pacific Islander
Black/African American
Hispanic/Latino
Native American or American Indian
White
Other:
Prefer not to answer

Position:

School:

Office Telephone:

Office Email:

District/Employer:

School Address:

City:

State:

Zip:

Note: Your information will not be shared with individuals or organizations at any time and will be used for KASA purposes only. This information also enables us to contact you in the event of an emergency.

Do you prefer that we mail your KASA materials to your home or to your office?

Home Office

If renewing, were you a member last year?
Yes No

How did you hear about KASA?

Please specify (if Other):

KASA Membership Categories & Annual Dues
Rate Schedule (Choose One):

Professional Member -- Annual Salary x .0032:

Professional Lifetime Member -- Annual Salary x .052:

One-time Payment; must be paid in lump sum

School leader assigned administrative/supervisory duties at the local school or district level; a vocational school administrator; an employee of a university or college who trains teachers and administrators; an employee of the Kentucky Department of Education; or an employee of other state education interest groups, commissions, and councils.

Enter your annual salary in the Members Dues Worksheet for dues calculation.

Premier Member -- Annual Salary x .0052:

Includes liability insurance

Premier Lifetime Member -- Annual Salary x .082:

One-time Payment; must be paid in lump sum - includes liability insurance

***

Enter your annual salary in the Members Dues Worksheet for dues calculation.

Associate Member -- $89:

Designed for teachers, librarians, college/university professors and classified employees of a school district or other education group.

Ineligible to serve on the board or committees, vote or receive legal funds

Emeritus Member -- $59

Available to retired school administrators not working in schools or education agencies and who have been a member of KASA for five consecutive years.

Ineligible to receive legal funds or enroll in the liability insurance program

Member Dues Worksheet: (Note: Do not use commas or periods when entering numerical amounts.)

1. Enter your annual salary

2. Multiply your salary by

3. Member Dues

KASA Affiliate Membership Categories: ( Note: As a member of KASA, we encourage you to join AASA. KASA will submit your membership information and payment to AASA on your behalf. )

American Association of School Administrators (AASA)

Membership Dues: (from worksheet above)
Affiliate Membership Dues: (from list above)
TOTAL DUES:
*Professional Liability Coverage:** $105 (Fee Disclosure: Please be advised that the $105 insurance cost represents a $46 premium, $4.41 state tax fee, and $54.59 policy plan management fee.)
(* Optional coverage, MUST BE PAID IN LUMP SUM. Cannot be paid through payroll deduction, must be paid by check OR credit card only. Available to KASA members only.)
GRAND TOTAL:

*Required Legal Notice -- Please Read.* KASA dues may be partially deductible as a business expense. KASA estimates that 90% of your dues are deductible. 10% supports KASA’s advocacy activities which are not deductible. *************************
*Cancellation Policy* Membership automatically renews each year unless written cancellation request received for membership termination. For cancellations that occur during the membership year, member will be invoiced for the portion of the year in which benefits were received. I agree to KASA's cancellation policy. * REQUIRED *************************
Dues Payment Options Option 1: Direct Pay Method (payment in one lump sum) Payment Enclosed (Mail check to KASA, 87 C. Michael Davenport Blvd., Frankfort, KY 40601.) Charge my Credit Card (3% convenience fee applies) American Express VISA MasterCard Discover
Name On Card:
Account No:
Expiration Date:
CVV number:
Billing Zip Code:
Amount Authorized for Charge:
Purchase Order My school district has issued PO # for items listed above.
	Please mail an invoice to my school district. I have printed this membership form, submitted to my district, and a check will be mailed in the near future.

Option 2: Automatic Payroll Authorization Deduction Method (APA) for KASA & Affiliate Membership Dues ( NOTE: Available for Professional, Premier, and Associate only ) I hereby authorize the payroll officer of my school district to deduct my KASA and/or affiliate dues and KASA insurance (excluding professional liability insurance) in 8 equal deductions in accordance with the dues structure in the KASA Constitution. Deduct the amount for insurance (excluding professional liability insurance) as authorized by me, in accordance with the rates and coverage schedule included in the insurance company brochure(s). This authorization is to remain in full force and effect unless revoked by me in writing. Note: If electing this option, please mail paper copy to KASA, 87 C. Michael Davenport Blvd., Frankfort, KY 40601.
Choose Your District ( Note: If your district is not listed, it is not participating in the APA program at this time. )

Option 3: ACH ( Electronic Banking ) for KASA & Affiliate Membership Dues I understand I will be contacted for my banking information for eight equal payments to be deducted October through May. ( NOTE: Amy Moore will contact you to complete this process. )

Please Charge my Credit Card $108.15 ( $105 + 3% convenience fee ) for my Liability Insurance


ABOUT SSL CERTIFICATES

American Express VISA MasterCard Discover

Name On Card:

Account No:

Expiration Date:

CVV number:

Billing Zip Code:

Image Verification

(type the answer to the math problem)
MUST complete in order to submit application

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87 C. Michael Davenport Blvd.
Frankfort, KY 40601
(800) 928-KASA or
(502) 875-3411
Fax (502) 875-4634