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This gift is to honor this individual as someone special and/or as someone who has made a significant contribution in your professional life.

I am recognizing the person whose name is indicated on the below form with an AASCD Legacy Membership.

Legacy Memberships are $50 per year.

Name: *

Email: *

Name of School or Organization: *

Preferred Phone: *

Preferred mailing address: Home Office *

Street: *

City: *

State *

Zip: *

Your input, for the following information, will help us to determine where we need to focus our efforts as an association in our goal to obtain a diverse AASCD membership. The following information is optional (needed for affiliated report):

Indicate your most accurate position title: Select One Dir. of Curriculum or Instruction District Level Admin. or Specialist Principal/Asst. Principal Superintendent/Asst. or Assoc. Supt. Supervisor Full-time Student Professor, Dean or other University Teacher NBCT Teacher Instructional Facilitator Counselor Career & Technical Adult Education Other

Gender: Male Female

Age: Under 45 Over 45

Geographic Region: Select One NW NE Central West East NE

Ethnicity: Select One African American Asian Caucasian Native American Hispanic Other

This Legacy Membership gift is given by:

Name: *

Email: *