Membership Application

Complete the form below and then print the page. Next, send the completed form along with your check made out to PSAHPERD, Inc. to the address at the bottom of the form. Thank you for your affirmation toward professional growth.

First Name
 Last Name
 Middle Initial
Street Address
City
 State
 Zip Code
Home Phone
School/Organization/Agency
 Professional County
Work Phone
 FAX
 E-mail
Student Graduation Date
 College/University
Select your membership type by clicking on the drop down box and highlighting your membership.

Please select one:

New Membership
Renewed Membership

Check your area(s) of interest from the choices below:

Adapted Activities
Aquatics
Health
Physical Education
Recreation
Dance
Men's Athletics
Women's Athletics
Sport Management

Print Form . . . Make check payable to PSAHPERD, Inc. and mail to:
Linda W. Huber
202 East Third Avenue
Lititz, PA 17543
(717) 627-1176
FAX (717) 627-4808