Massachusetts Adult Day Services Association

ASSOCIATE/BUSINESS PARTNER-MEMBERSHIP APPLICATION FORM 2016-17

Company: ______

Contact Person’s Name & Title: ______

Address: ______City: ______

State: ______Zip Code: ______Phone: ______

Fax: ______Email: ______

Website: ______

ONLY MADSA Members receive discounts and increased visibility via:  Discounts on Vendor Exhibit Tables at MADSA Statewide Membership Meetings  Adult Day Health and other important updates through MADSA’s E-Bulletins  Listing in our Statewide Membership Directory  Listing and link to your website on and from the MADSA website

MADSA is your trusted information source and members receive:  Accurate, reliable, up-to-date information on changes and trends, regulations and laws that affect Adult Day Health Programs  The benefit of MADSA leadership working on your behalf on issues including rates, regulations and legislation, affecting the quality and availability of Adult Day Health Services

Associate Dues for the membership year September 1, 2016 – August 31, 2017 below. Please check one: Dues Amount due

 Individual $200 (ADH Participants, Family Members or Students ONLY)

 Business Partner/Organization or Association $500 /Professionals/ADH Program–Pre-Opening/All Others

ADH Programs or affiliated organizations or individuals may NOT join as Associate Members.

On behalf of the applicant(s) listed herein (“Applicant”), I hereby certify that the contents of this application are accurate and complete. The Applicant agrees to advise MADSA of any significant changes in management, ownership or other similar material changes to the membership information that may affect its membership or the information provided herein. The Applicant agrees to abide by MADSA’s Bylaws, membership rules, requirements and policies, including but not limited to the Membership and Payment of Dues Policy, Vendor Exhibit Table application/policy (encl.) and decisions of the Board regarding membership/dues. The Applicant acknowledges that membership may be terminated at any time if the Board reasonably determines in its sole discretion that this application contains false or misleading statements/information or for violation of MASDA’s membership requirements. The Applicant, by its signature below, agrees to hold MADSA, its officers, directors, employees and agents harmless in regard to any and all actions taken, including membership termination, arising from or related to this application.

Signature (required)______Title:______Date ______

PLEASE enclose a brochure or information about your Group or Business. Please make checks payable to and mail with application form & payment to: MADSA One Florence Street Boston, MA 02131. Questions? Please call the MADSA office at 617-469-5848 or [email protected].