Join MSCSS!
MEMBERSHIP FORM

(Click Here for Membership form printable version)

Please indicate types of membership
Individual Annual MSCSS Dues - $ 25.00_____
Institutional Membership Dues - $ 50 00_____ (LIMIT 3 individuals per school - See
below)
Full Time Student Annual Dues - $10.00_____ ( Enclose Copy of Student ID)
Retired Teacher Annual Dues - $15.00_____
Spouse of MSCSS Mernber Dues - $10.00 _____

TOTAL MEMBERSHIP DUES ENCLOSED________

Member Information (PLEASE PRINT CLEARLY)
Name ________________________________________ Date _______________
Home Mailing Address _______________________________________________
School Name and Mailing Address ______________________________________
Phone (Home) ____________________ (School)__________________________
Email Address_______________________

INSTITUTIONAL MEMBERSHIP: If this will be an institutional membership, list below
the two other names as contacts. Primary contact will be the person listed above.
PLEASE PRINT INFORMATION.
Contact # 2 Name________________ Contact # 3 Name___________________
Position ________________________ Position ___________________________
Address _______________________Address_____________________________
Email Address ____________________ Email Address______________________

Return application with check made payable to "MSCSS" and mail to:
Ruth Stas • Treasurer MSCSS • P.O. Box 5162, Lancaster, PA 17606;          
(717)-468-6319