Wufoo
2017 Ohio AHEAD Membership Form
Please complete this form to become an OH-AHEAD member for 2017. Your membership will be complete upon submission of this form and confirmation of payment.
Professionals who are part of an Institutional Membership will also need to have the person responsible for payment complete the Institutional Membership Payment Form (https://ohahead.wufoo.com/forms/qn7pry514na7j5/).
Membership categories:
Institutional/District Membership is $75.00 for up to three (3) members within an institution and $15 for each additional member.
Individual Professional/Advocate Membership is $35.00.
Individual Professional Retiree Membership is $15.00.
Student (undergraduate or graduate student enrolled at least six (6) semester hours interested in the field of disability services in higher education and/or participating in disability services) is $15.
My membership is:
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Individual Membership
Institutional Membership
Student Membership
Retiree Membership
Note About Institutional Memberships
Institutional Memberships (see pricing above) can be paid via check or by PayPal on the "Institutional Membership Payment Form." That payment form should be completed by the person responsible for payment.
Institutional members should NOT pay for their own membership using the payment options on this membership form, unless they are a late addition to the institutional membership as a +1.
Name
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First
Last
Institution/Agency
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Business Address (see labels below each box)
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Australia
Canada
France
New Zealand
India
Brazil
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Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong SAR China
Hungary
Iceland
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau SAR China
Republic of North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé & Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Helena
St. Kitts & Nevis
St. Lucia
St. Martin
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Outlying Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Email
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Office Phone Number
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Office Fax
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TTY/Videophone
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Institution Type
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4-year Private College/University
4-year Public College/University
2-year Community College
Regional Affiliate of a College/University
Technical/Vocational College
K-12 District
Adult Basic Literacy Education/Adult Workforce Education
Agency/Non-profit Affiliation
Other
Maximum of
250
characters.
Currently Used:
0
characters.
I would like to join the following Ohio AHEAD committees:
Please see http://ohioahead.org for specific committee information.
Membership
Communications
Conference
Is there a specific area(s) of interest relative to accessibility/disability that you would like the Ohio AHEAD Board to consider for future conferences, webinars, or as resources for our website? If so, please list.
How will you be handling payment?
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I have already paid for my individual/student membership through conference registration.
I am part of an institutional membership, which will be paid for via the Institutional Memb. Payment Form.
I will be paying via Paypal.
I will be paying via check.
Thank you for paying for your 2017 individual/student membership in conjunction with your 2016 conference registration.
Please finish your membership application by clicking "submit" below.
Who is the person responsible for payment? (i.e. who will be completing the Institutional Membership Payment Form?)
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Please select the membership type you'll be paying for with Paypal.
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Individual Membership ($35)
+1 to an existing Institutional Membership ($15)
Student Membership ($15)
Retiree Membership ($15)
PayPal is the processing company for credit card payments. A PayPal account is not required.
Check Payment Instructions:
Membership checks should be made payable to Ohio AHEAD and should be mailed to:
Adam Crawford (Ohio AHEAD Treasurer)
The Ohio State University
Disability Services
098 Baker Hall
113 W. 12th Ave.
Columbus, OH 43210
Please include your name and "membership" on the check memo.
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