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San Antonio Dietetic Association
Membership Application for 2010 - 2011

Membership year runs from June 1, 2010 to May 31, 2011 (dues are not prorated).

Use this form to apply directly to SADA. When you click Submit, we will be emailed notifying us of your application. To update your information please type your name and then any areas that need to be changed.

Last Name
 *
First Name
 *
Email *
Credentials
ADA #
Licensure
Title
Office Location
Work Address
Work City
State
Zip Code
Work Phone
Work Fax
Pager
Home Address
Home City
State
Zip Code
Home Phone
Home Fax
Home Information Restricted?
 Yes No
Willing to speak for groups?
 Yes No
Topics
Bilingual?
 Yes No
Area of Expertise
Willing to be a volunteer?
 Yes  No
Are you retired?
 Yes  No

If "Yes", please select the areas in which you would like to help:
All Areas

Association Events:
Greeter
Christmas Party
Spring Seminar
Planning
Scholarships

Legislative Events:
PAC Fundraising
Day at the Capitol

Public Relations Events:
Health Fairs
San Antonio Fit City Initiatives
Other

Other Information:
List any ADA Dietetic Practice Groups that you are a member of...
List any other associations that you are a member of or hold a position in?
Select all that you apply to:
  
Medicare
Medicaid
Private Insurance
Do you plan on becoming a Medicare provider?
 Yes No
 

All dues are payable by May 31st.

Please allow 4-6 weeks for the processing of your application. Processing will begin upon receipt of your dues payment.

Submit your Application and pay your dues using PayPal
(Retired members pay no dues- click Submit but do not pay using PayPal)

   
* Required

 
 
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