Author: Michelle Stopak

2020 Activity Professionals Association
Membership Form
Dues $20.00 payable at monthly lunch and learns or you can mail it to Vicki Andress @ Immanuel Communities 6803 nth 68th plaza
Omaha Ne. 68152
Name: ______________________________
Title: ______________________________
Place of Employment: _________________________________
Category: Assisted Living, Memory Support, Skilled, Rehab, PACE, Other: ___________________________
Work Address:_______________________________________
Work Phone: ________________________________________
Work e-mail: ________________________________________
Population you serve: __________________________________
Personal information ( optional)
E-mail address:______________________________________
Mailing Address: ______________________________________
Cell Phone:__________________________________________________
MAKE CHECKS PAYABLE TO ACTIVITY PROFESSIONALS ASSOCIATION