Membership Application | National Adult Day Services Association

Membership Dues

Organization Code

If you were given a code to sign up for an organization, enter it now and hit the submit button

Membership Type *

Add-On Password

You must create a password that will be used by your members to join your organization. You will be given instructions at the end of the member application on what information to pass onto your members, and how they can join.

Contact Information

Email *

Re-enter your email *

Prefix

First Name *

Last Name *

Suffix

Title

Informal Name

Company *

Address 1 *

Address 2

Address 3

City *

State

Zip Code *

Website

Phone Number *

Fax Number

CCMail

Include me in Membership Directories *
Yes No

Include me in Broadcast Email *
Yes No

Member Login/Password

Please enter the Member Login/Password you would like to use to login to this website.

Your Member Login must be unique and must be at least 6 characters.
Passwords must be a minimum of 8 alpha-numeric characters with at least 1 number or 1 letter.

Member Login *

Password *

Confirm Password *

Additional Information

Tax Status

Organization Type *

Number of employees at this location

County

Date Center Opened

Name of Parent Organization/Owner (if applicable)

Center Capacity

Model

Physical Location

Number of Locations

Payment Details

Comments

Discount

Payment Method

Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.

Account Type

Checking

Savings

Routing Number

Account Number

Account Holder Type

Business

Personal

Business Name

Account Holder Name

By submitting payment, I am authorizing National Adult Day Services Association to initiate a single or recurring ACH/electronic debit in the amount indicated from the bank account I designated above. I understand that this Authorization will remain in full force and effect until the transaction is cancelled by me by contacting National Adult Day Services Association, or the ACH/electronic debit is processed from the designated account. I certify that (1) I am authorized to debit the bank account above and (2) the ACH/electronic payment I am authorizing complies with all applicable laws.

Name on Card

Card Number

Expiration

CSC

Billing Street

Billing Zip Code

Save payment method for future purchases

Total Amount Due

Enable Automatic Renewals? *

Select "Yes" to enroll in automatic membership renewal. The payment method submitted with this form will be used for your future membership renewals. You can change the automatic renewal setting or saved payment method at any time in either the "Payment Methods" or "Renewal Settings" where you edit your profile.

Yes

Center Memberships

Membership Dues

Contact Information Contact Information

Member Login/Password Member Login/Password

Additional Information Additional Information

Payment Details Payment Details

Contact Information

Member Login/Password

Additional Information

Payment Details