Membership Application Form
(Please Print Out this Form)
Name: __________________________________________________
Home Address: ___________________________________________
City: ____________________________ Zip: ___________________
Home Phone: ___________________ Work Phone: ______________
E-mail: __________________________________________________
Agency: _________________________________________________
Agency Address: __________________________________________
Current Position: __________________________________________
Length of Employment in Child & Youth Care Work: _____________
Supervisor's Name: _______________________________________
Type of Membership: (check one)
Full Membership: _____ Associate Membership: _____
Annual Dues: (check one)
One (1) Year: ____ at $20.00 (US funds)
Two (2) Year: ____ at $35.00 (US funds)
Please mail this application and a check (payable to OACYCP) to:
Ohio Association of Child & Youth Care Professionals, Inc.
2411 Seaman Street
Toledo, Ohio 43605
