Download PDF version of membership application
Complete form and send to KASA.
Fax: (502) 875-4634
Email: Tammy Newcome
Mail: KASA 87 C. Michael Davenport Blvd. Frankfort, KY 40601
Questions? Call the KASA office at (800) 928-KASA
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: January February March April May June July August September October November December Birth day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 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: District 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.
New Member or Renewal
Home Office
What method do you prefer to receive your materials?
Electronic (email) Paper
How did you hear about KASA? Please Choose One Received Mail from KASA Attended a KASA Event Word of Mouth KASA Website / Social Media KASA Ambassador Other Please specify (if Other):
KASA Membership Categories & Annual Dues Rate Schedule (Choose One):
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: Affiliate organization memberships are NOT included with KASA Lifetime memberships, and will renew annually. ( Note: As a member of KASA, we encourage you to join any of our affiliate organizations. KASA will submit your membership information and payment to the affiliate no later than the 15th of the following month. Participation is contingent upon KASA membership. )
Membership Dues:
(from worksheet above)
Affiliate Membership Dues:
(from list above)
(* 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.)
Required Legal Notice--Please Read. KASA dues are not deductible as a charitable contribution for Federal income tax purposes, but may be partially deductible as a business expense. KASA estimates that 10% of your dues are not deductible because of KASA's lobbying activities on behalf of its members.
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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
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.
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.
Please Charge my Credit Card $104.03 ( $101 + 3% convenience fee ) for my Liability Insurance ABOUT SSL CERTIFICATES
Image Verification (type the answer to the math problem) MUST complete in order to submit application