BACK
Mississippi Association of Diabetes Educators ~ Miss-ADE
Membership Application / Renewal
January 1, 2010 until December 31, 2010
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 $30.00 per year and are due by January, 1st. Please send this completed
form and your dues to:  Miss-ADE, Inc.
596 Clifton-Hillsboro Road
Lena, Ms 39094
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.
Preferred mailing address: ___________________________________________________________
City: ______________________________________  State: _______________ Zip: ______________
Home Phone #: _____________________ Fax: ____________________

Preferred Email: ____________________________________________

Work Institution: ___________________________________________

Work Phone #: _____________________ Fax: ____________________

(For Miss ADE communication)

Are you a CDE?   Yes  -  No           Initial year of Certification: _______________

Are you a BC-ADM?   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?
3.  If you can not receive your newsletter and other communication from Miss ADE by email
     please provide mailing address: ____________________________________________________
4.  Do you have a program that is already approved for CEU’s that you would like to present at
     a quarterly meeting?
     ________________________________________________________________________________
    
Miss-ADE Home | Membership | Newsletter | Education | Officers | Sponsors | Advocacy | Links