FADCA/NADSA Membership Application
FADCA membership fees INCLUDE the National Adult Day Services Association (NADSA) membership and will expire on December 31st.

To apply by mail: Fill in all boxes below,DO NOT CLICK ON "SEND MESSAGE" box, print page and mail with payment to: Florida Adult Day Care Association, 5200 NW 43rd Steet, #102 PMB-310, Gainesville, FL 32606

To apply on-line with Credit Card Payment: Fill in boxes below, enter credit card information for payment, click on "Send Message" Box to submit. When registering on-line through electronic means, a name entered into the "Authorizing Signature" box will be considered an offical signature and will validate this agreement. An actual signature should appear on forms sent through mail.
A. Center Member - $195 Annual - Orgainizations licensed by the Florida Agency for Health Care Admin. to provide adult day care. (yes or no)

B. Individual Member - $ 135.00 - Persons interested in sporting adult day services in Florida. Individuals need not be currently affilitated with a licensed Florida Adult day care center. (yes or no)

C. Corporate Member - $310 Annual - Organization interested in supporting adult day services. Member organizations need not be affiliated with a licensed Florida adult day care center. (yes or no)

D. Web-site Link - $60.00 additional fee (yes or no)

E. Agency/Organization:

F. Name:

G. Title:

H. Mailing Address:

I. City:

J. State:

K. Zip:

L. Phone:

M. Fax:

N. E-mail:

O. Web-site Address:

P. County:

Q. Center License #:

R. Center Capacity:

S. For Profit or Non-Profit: (list which)

T. Name on Credit Card:

U. Credit Card Number:

V. Expiration Date:

W. Authorizing Signature:

X. Total Amount Paid:

Comments: