central New york

arts-in-education roundtable

Membership Application

Name

Affiliation: Artist ______ Educator ______ Organization ______

Brief Description ______________________________________________________________

____________________________________________________________________________

Address

City State Zip

Mailing Address (if different) _____________________________________________________

________________________________________________________

City State Zip

Phone ( )  ______________   Fax ( ) _________________ Mobile ( ) _______________

Web address

Email

I certify that is a member in good standing, and I agree to attend

at least two of four CNYAER meetings per roundtable program year (October – June annually)

___________________________________ ______________________________

SIGNATURE Date

I will be the roundtable member attending as a representative of the following organization,

with full support of the executive director:

___________________________________ ______________________________

Executive Director Signature Date

Please mail or fax this form to:

Partners for Arts Education

501 W. Fayette St., Studio 221

Syracuse, NY 13204

Fax: 315 234 9912