Miss-ADE Membership Form


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	Mississippi Association of Diabetes Educators ~ Miss-ADE Membership Application / Renewal July 1, 2007 until June 30, 2008
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	Mission: Dedicated to advancing the role of the Diabetes Educator, and improving the quality of diabetes education and care of the people we serve.

	Miss-ADE dues of $25.00 per year and are due by July, 1st. Please send this completed form and your dues to: Miss-ADE, Inc. P.O. Box 172 Tupelo, MS 38802

	Name: ____________________________________ Your Credentials: _______________________
	License # (for CE purposes): _________________________________ State: __________________
	*Are you an AADE member? Yes - No If member, membership #:** ________________________
	* Must be furnished to determine appropriate status.
	HOME Address: ___________________________________________________________________
	Home Phone #: ___________________ Fax: __________________ Email: ____________________
	WORK Address: Institution: ______________________________ Street / Box #: _____________________________
	City: ______________________________________ State: _______________ Zip: ______________
	Work Phone #: ___________________ Fax: __________________ Email: _____________________
	Are you a CDE? Yes - No Initial year of Certification: _______________

	Please circle / answer the following questions:
	1. Areas of interest in which you would be willing to serve:
	Program Committee Membership Advocacy
	2. Would You be willing to serve a 2-year session as an elected officer of Miss-ADE?
	President Elect Secretary Treasurer Nominating Committee Historian
	3. How would you like the Newsletter to come to you?
	Regular Mail E-mail Website
	4. Do you have a program that is already approved for CEU’s that you would like to present at a quarterly meeting?
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