MALC.registration.form

** Membership Application **
 * Michigan **** Adolescent Literacy Council **

(MALC) ||
 *  || Michigan Adolescent Literacy Council

Name
 * I am a member of (please circle):

// International Reading Association // ¨ YES ¨ NO  IRA Membership #

__ // Michigan Reading Association // __ __ ¨ YES  __ __ ¨ NO  __ __ MRA Membership # __ ||
 * <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt; line-height: 150%; margin: 0in 0in 0pt;">Address ||
 * <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt; line-height: 150%; margin: 0in 0in 0pt;">City _____ ||
 * <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt; line-height: 150%; margin: 0in 0in 0pt;">Zip Code _____ ||
 * <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt; line-height: 150%; margin: 0in 0in 0pt;">County _ ||
 * <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt; line-height: 150%; margin: 0in 0in 0pt;">Phone ||
 * <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt; line-height: 150%; margin: 0in 0in 0pt;">E-mail _____ || <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Please remit payment to:

__<span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt; margin: 0in 0in 0pt;">Michigan Adolescent Literacy Council __ __<span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt; margin: 0in 0in 0pt;">Maureen Baker __ __<span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt; margin: 0in 0in 0pt;">Tri County High School __ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt; margin: 0in 0in 0pt;">

<span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Method of Payment: __ ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Check  __ __ ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">MasterCard  __ __ ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Visa  __ __<span style="display: block; font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 9pt; margin: 0in 0in 0pt 0.25in; text-align: center;">/// __ __ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Expiration Date: <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 9pt;"> /  __

<span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Payment: __ ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Regular Member……..$10  __ __ ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Non MRA member…..$10  __ || ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Teacher ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Administrator ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Title I   ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Paraprofessional ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Adult Education ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Elementary ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Middle ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Secondary ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">University ¨ <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt;">Other ___ ||^   ||
 * <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt; line-height: 150%; margin: 0in 0in 0pt;">School District ||^   ||
 * <span style="font-family: 'Tw Cen MT Condensed Extra Bold','sans-serif'; font-size: 14pt; margin: 0in 0in 0pt;">Check all that apply: