VAHPERD MEMBERSHIP APPLICATION
Ms. Mrs. Mr. Dr.
Name:______Date:______
Address where you prefer to receive VAHPERD materials:
______
Street City State ZIP Code
Telephone: (______) ______E-mail Required: ______
Type of Membership: Full-time Student $ 15.00
Active professional (1 yr) $ 40.00
Active professional (3 yrs) $ 95.00
HFH/JRFH Event Coordinator $ 15.00
(Verified by AHA)
Retired $ 20.00
Employment Level (check all that apply)
Elementary
Middle school
High school
College/university
Other ______
(Please specify)
Divisions:
Dance
Health
Physical education
Recreation, Sport, and Leisure
Sections: check areas of interest
Dance Division (Sections)
Dance education K-12
Dance performance
/ General Division (Sections)
City/county supervisor
College/university Faculty
Exercise Science
Research
Sports management
Students
Health Division (Sections)
College/University health
School health
Community/Worksite health
Physical Education Division (Sections)
Adapted
Elementary
Middle school
Secondary school
College/University
Recreation, Sport and Leisure Division
Leisure Activities
Recreational Sports
Outdoor recreation
Committees
Structure and Function
Membership
Necrology
Convention
Awards
Finance
Legislative Affairs
Nominating
Convention Volunteer
IMPORTANT REGION INFORMATION: ______/ Indicate region of employment (See back for region code information)
Status: Renewing New Member
Payment Amount: $ ______
GCheck enclosed
GCredit card:G VISA G MasterCard G American Express G Discover
Account no: ______- ______- ______- ______Expiration Date ______
Credit Card CVV/CVC ______
Address where credit card statement is mailed (if different from address above):
______
Street City State ZIP Code
Signature: ______
Mail form to
VAHPERD
1901 James Overlook Dr
Chester, VA 23836
Region I
I-1: / Charles City County / I-6: / Chesterfield County / I-11: / Colonial Heights CityI-2: / Dinwiddie County / I-7: / Goochland County / I-12: / Hanover County
I-3: / Henrico County / I-8: / Hopewell City / I-13: / New Kent County
I-4: / Petersburg / I-9: / Powhatan / I-14: / Prince George County
I-5: / Richmond City / I-10: / Surry County / I-15: / Sussex County
Region II
II-16: / Accomack / II-21: / Chesapeake City / II-26: / Franklin CityII-17: / Hampton City / II-22: / Isle of Wight / II-27: / Newport News City
II-18: / Norfolk City / II-23: / Northampton / II-28: / Poquoson City
II-19: / Portsmouth City / II-24: / Southampton / II-29: / Suffolk City
II-20: / Virginia Beach City / II-25: / Williamsburg City / II-30: / York
Region III
III-31: / Caroline / III-37: / Colonial Beach / III-43: / EssexIII-32: / Fredericksburg City / III-38: / Gloucester / III-44: / King George
III-33: / King Queen / III-39: / King William / III-45: / Lancaster
III-34: / Mathews / III-40: / Middlesex / III-46: / Northumberland
III-35: / Richmond County / III-41: / Spotsylvania / III-47: / Stafford
III-36: / West Point / III-42: / Westmoreland
Region IV
IV-48: / Alexandria City / IV-55: / Arlington / IV-62: / ClarkeIV-49: / Culpeper / IV-56: / Fairfax / IV-63: / Fairfax City
IV-50: / Falls Church City / IV-57: / Fauquier / IV-64: / Frederick
IV-51: / Loudoun / IV-58: / Madison / IV-65: / Manassas City
IV-52: / Manassas Park City / IV-59: / Orange / IV-66: / Page
IV-53: / Prince William / IV-60: / Rappahannock / IV-67: / Shenandoah
IV-54: / Warren / IV-61: / Winchester City
Region V
V-68: / Albermarle / V-76: / Amherst / V-83: / AppomattoxV-69: / Augusta / V-77: / Bath / V-84: / Bedford
V-70: / Bedford City / V-78: / Buena Vista City / V-85: / Campbell
V-71: / Charlottesville City / V-79: / Fluvanna / V-86: / Greene
V-72: / Harrisonburg City / V-80: / Highland / V-87: / Lexington City
V-73: / Louisa / V-81: / Lynchburg City / V-88: / Nelson
V-74: / Rockbridge / V-82: / Rockingham / V-89: / Staunton City
V-75: / Waynesboro City
Region VI
VI-90: / Alleghany Hglnds / VI-95: / Botetourt / VI-100: / Covington CityVI-91: / Craig / VI-96: / Danville City / VI-101: / Floyd
VI-92: / Franklin / VI-97: / Henry / VI-102: / Martinsville City
VI-93: / Montgomery / VI-98: / Patrick / VI-103: / Pittsylvania
VI-94: / Roanoke / VI-99: / Roanoke City / VI-104: / Salem City
Region VII
VII-105: / Bland / VII-112: / Bristol City / VII-118: / BuchananVII-106: / Carroll / VII-113: / Dickenson / VII-119: / Galax City
VII-107: / Giles / VII-114: / Grayson / VII-120: / Lee
VII-108: / Norton City / VII-115: / Pulaski / VII-121: / Radford City
VII-109: / Russell / VII-116: / Scott / VII-122: / Smyth
VII-110: / Tazewell / VII-117: / Washington / VII-123: / Wise
VII-111: / Wythe
Region VIII
VIII-124: / Amelia / VIII-128: / Brunswick / VIII-132: / BuckinghamVIII-125: / Charlotte / VIII-129: / Cumberland / VIII-133: / Greensville
VIII-126: / Halifax / VIII-130: / Lunenburg / VIII-134: / Mecklenburg
VIII-127: / Nottoway / VIII-131: / Prince Edward