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Membership Application
 You may complete this form online and print it out or print it out 1st and complete on paper.

New
Renewal
Date
Name
Position Title
Facility Name
Facility Address
Facility Phone Number
Facilty Fax Number
Facility E-Mail Address
Home Address
Home Phone Number
Home Fax Number
Home E-Mail Address
Location to send mail
Home Work

Active Membership
($30.00/Two Years)

I am applying for active membership by virtue of activity or social services assistant, consultant or director in
Long Term Care
Senior Retirement Housing
Senior Center
Adult Day Care
Related Through Social Services
Hospital
Other (please specify)

Associate Membership
($20.00/Two Years)

I am applying for associate membership by virtue of
Retired Activity Professional
Student
Volunteer
Senior Citizen
Other (please specify)

Make check payable to WVAPA and mail to
Summers Nursing and Rehab
Chastity Richmond
HC 85 Box 22
Jumping Branch WV 25969
Home: (304) 222-7099
crichmond*amfmwv.com

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