24-25 NCSSWA Membership Application

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24-25 NCSSWA Membership Application

Please complete the form if you desire to become a member of the North Carolina School Social Worker Association. Cost: Student/Retiree Membership-$25 Professional Membership-$40. Payments can be made by check and mailed to NCSSWA Treasurer P.O. Box 82, Elm City, NC 27822. You may also use Credit/Debit, PayPal or Cash App. Usernames are listed below. Thank you.

First Name *

Last Name *

Work Email *

Current Address *

Phone Number *

Membership *

Professional

Student

Retiree

If you are a student, please list the University Program you are attending. If you are a retiree, please list the School System from which you retired. If neither applies to you, simply write in not applicable (N/A).

Job Title *

School System *

County *

What region are you located? *

CENTRAL (Alamance, Caswell, Chatham, Durham, Franklin, Granville, Guilford, Harnett, Johnston, Lee, Nash, Orange, Person, Randolph, Rockingham, Vance, Wake, Warren, Wilson)

NORTHEAST (Beaufort, Bertie, Camden, Currituck, Dare, Edgecombe, Gates, Halifax, Hertford, Hyde, Martin, Northampton, Pasquotank, Perquimans, Pitt, Tyrell, Washington)

NORTHWEST (Alexander, Alleghany, Ashe, Burke, Caldwell, Catawba, Davidson, Davie, Forsyth, Iredell, Stokes, Surry, Watauga, Wilkes, Yadkin)

SOUTHEAST (Bladen, Brunswick, Carteret, Columbus, Craven, Cumberland, Duplin, Greene, Jones, Lenoir, New Hanover, Onslow, Pamlico, Pender, Robeson, Sampson, Wayne)

SOUTHWEST (Anson, Cabarrus, Cleveland, Gaston, Hoke, Lincoln, Mecklenburg, Montgomery, Moore, Richmond, Rowan, Scotland, Stanly, Union)

WESTERN (Buncombe, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, Yancey)

Form of Payment * *

Check written to NCSSWA, PO Box 82, Elm City NC 27822

Money Order written to NCSSWA, PO Box 82, Elm City NC 27822

PayPal @vbncsswa2020 (Please include processing fee $2.02 for $40 pymt and $1.10 for $25 pymt.)

Cash App $ncsswa22 (Please be sure to include your name if your cash app differs from original name)

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