Florida Association of School Social Workers
Membership Application Form

Print out and mail to address below

PLEASE TYPE OR PRINT

Name __________________________________________________________________

Home address ___________________________________________________________

_______________________________________________________________________

County of Residence ______________________________________________________

Home Phone ____________________________________________________________

Fax ___________________________________________________________________

Email __________________________________________________________________

Work Information

Employer _______________________________________________________________

Department _____________________________________________________________

Work title ______________________________________________________________

Professional Information

Degree(s) ______________________________________________________________

License(s) ______________________________________________________________

National Credential(s) _____________________________________________________

And/or Certificate(s) ______________________________________________________

Legislative Information* (Residence only)

State Senator or district ____________________________________________________

State Representative or district _______________________________________________

*Not sure? Check with your local Elections Office or look on your voter card.

Annual Membership Fees:

____ Check if you are renewing your FASSW membership

____ Joining or renewing membership in SSWAA = $50.00
Make separate check payable to SSWAA for $50.00 and we will forward it for you. Note: SSWAA membership, when NOT renewing with FASSW is $75.00.

Whether paying by check, or through PayPal, please print form and send to:

Vicki Barreneche
8716 Cobbler Place
Tampa, FL 33615