2017-2018 AND-STL Membership Form
Membership Applications are due September 29, 2017. Please note there will be a late fee ($5) if submitting this after this date. You must be a current AND member to join the Academy of Nutrition and Dietetics of St. Louis. Please go to www.eatright.org to register for your AND membership before submitting this registration form.

Thank you!

Last Name *
Your answer
First *
Your answer
Previous name (If name changed in the past year)
Your answer
Credenentials
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Preferred Contact Address *
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Preferred Phone Number *
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Alternate phone
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Preferred Contact Email *
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Alternate Email
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Area of Practice or Job Title *
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Company
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If student, name of school or program
Your answer
AND membership number (please note if affiliation is not Missouri) *
Your answer
Please choose your membership type: *
Do you work for a company that would sponsor AND-STL meetings? If yes, please provide information below.
Your answer
Would you be interested in getting more involved by serving on an AND-STL committee, running for a board position, or helping out with NNM activities?
If so, great! Please tell us what you are interested in:
Your answer
Membership Dues & Donations
Please select/enter all of the appropriate options from the boxes below. Upon completion of this form, you will need to follow the links on the website to pay via PayPal (http://www.eatrightmissouri.org/page/st-louis-district).

Please note that application and dues must be submitted online.

Please select the appropriate membership option below: *
Required
Total Membership Dues *
Please enter the total amount you will be submitting.
Your answer
Donations
Donations are optional. If you would like to donate to any of the funds listed, please enter the amount of your gifts below.
AND-STL Public Policy Fund (Public Policy Workshop (PPW) Donation)
Please enter your donation amount below.
Your answer
AND-STL Legislation Fund (AND Political Action Committee Donation)
Please enter your donation amount below.
Your answer
AND-STL National Nutrition Month 2017 Fund
Please enter your donation amount below.
Your answer
AND-STL Scholarship Fund
Please enter your donation amount below.
Your answer
Thank you for joining the Academy of Nutrition and Dietetics of St. Louis! We appreciate your commitment to the organization and the community.
Please be sure to complete your payment(s) online using the PayPal links available on our website at http://www.eatrightmissouri.org/page/st-louis-district

Donations:
https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=XH8DQRZV786YY

Questions or comments?
Contact Christina Popp, AND-STL President, at membership@and-stl.org.
or Shannon Ebron, Corresponding Secretary, at ebronsee@gmail.com.

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