To become a member, print this page and fill it out completely. Mailing address is at the bottom.
Membership Form for the NEA Ex-Gay Educators’ Caucus
Name: Last_________________________________ First________________________ MI _______________
Postal Address _____________________________________________
City ____________________________ State ____________ Zip _______
Email address___________________________________
Home phone with area code______________________
Cell phone with area code___________________________
Issues of interest:
Is there a particular type of volunteer work you are interested in: (Check all that apply.)
____Public speaking/training ____ Writing letters ____ Fundraising
____ Research ____CPA, accounting, budget ____Lobbying
____ Distribute caucus brochures to your church, PTA, library, school, youth groups, etc.
____ Host a caucus exhibit booth in your area
____ Grant writing ____ Answering emails ____ Website management
Other (Specify): ________________________________________
Dues category: (Check one)
____ $20 for Active voting membership (NEA members only, including Staff and Life
____ $10 for Associate non-voting membership (non-NEA members have not caucus voting privileges)
____ $5 for Student NEA Members or Retired NEA Members (have voting privileges)
$________ Additional amount for any voluntary donations.
$ _______ Total amount enclosed
Make checks payable to Ex-Gay Educators’ Caucus (not tax deductible)
Please mail form and payment to:
NEA Ex-Gay Educators’ Caucus
P.O. Box 543
Cottage Grove, MN 55016
