Virginia Interscholastic Athletic Administrators Association

Virginia Interscholastic Athletic Administrators Association 2016-17 MEMBERSHIP APPLICATION

Mail Application & Payment To: Ryan Molloy, c/o Atlee High School…9414 Atlee Station Road, Mechanicsville, VA 23116…Email: [email protected]

Make Checks/Money Orders Payable To: VIAAA

First: ______M.I.______Last: ______DISTRICT: ______

Suffix: ______Informal First: ______Title (CAA/Etc.): ______REGION:______Year Certified:______School: ______Class: 6A, 5A, 4A, 3A, 2A, 1A INDP. M/S Retired School or Home Member NIAAA: Yes No Address: ______

City, State: ______, ______Zip: ______

Phone: (____) ______-______FAX: (____) ______-______E-MAIL______

Position: ______

MEMBERSHIP OPTIONS: ACTIVE MEMBER $115.00 ______(Dual VIAAA & NIAAA) RETIRED MEMBER $20.00 ______(VIAAA only) LIFETIME MEMBER $250.00______(VIAAA only) LIFETIME MEMBER VIAAA joining NIAAA $80.00______LIFETIME MEMBER NIAAA joining VIAAA $35.00______

NIAAA Membership Information ONLY Membership Office Use Only  New Membership Renewal Membership # ______Check/Money Order # ______Check/Money Order Date ______ Male  Female Social Security # ______- ______- ______ School  Personal  Money Order  Cash  Smoker  Non-Smoker Date of Birth ______

The NIAAA has formed an ad hoc committee to study diversity among our members. In this regard, a database has been instituted to collect this information from our membership applications. We appreciate your completion of this section so we may better serve our members. Please check one:

 Caucasian  African American  Asian  Pacific Islander  Latino  American Indian  Multi-Cultural  Alaskan Native

If none of the above codes seem appropriate, please indicate your background ______.

All Lifetime members must complete a Membership Application each year to verify your information.

Updated 4/27/16