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MEMBERSHIP APPLICATION

This information will be used for our OASCD directory. Membership lists are not sold to other organizations or entities.

Date Submitted
Name
Mailing Address
City, State, Zip
School/Institution
Home Phone with Area Code
Work Phone with Area Code
E-mail Address
Alternate E-mail address
Size of School District (circle the most appropriate response)	Under 500 students 501-5,000 students 5,001 - 15,000 students 15,001 - 25,000 students Over 25,001 students
Type of School (circle the most appropriate response)	Elementary School Secondary School Vocational School Higher Education State Agency Other (please describe)
Postion (circle the most appropriate response)	Teacher Administrator Counselor Support Staff Curriculum/Instruction Director Professor, Dean, or other University Other (please describe)
Geographic Location (circle the most appropriate response)	Northwest Oklahoma Southwest Oklahoma Northeast Oklahoma (excluding Tulsa Metro) Southeast Oklahoma Oklahoma City Metro Tulsa Metro
Length of Service (circle the most appropriate response)	Less than 5 years 5-10 years 11-15 years More than 15 years
Ethnicity (optional) (circle the most appropriate response)	African American Asian Caucasian Hispanic Native American Other
Gender (optional) (circle the most appropriate response)	Female Male

Paid by Check # ________
Purchase Order # ____________________

For more information, including membership and conference registration, contact:

OASCD
Post Office Box 773
Oklahoma City, Oklahoma 73101-0773
Wayne Beam, Executive Secretary
405.354.0297
beamoascd@cox.net