Oregon Reading Association Membership Application

Send this application with a check for $25 made out to ORA or credit card information (including security code) to:

Dennis Hickey
  (Your cancelled check or credit card statement is your receipt)
ORA Membership Director    
PO Box 12   (Note: Set your printer to print only page 1)
Maupin, OR 97037    

>>click here for smaller pdf application form to print and fill out<<

Date (12/15/03):
First Name: Last Name:
Address:
City: State: Zip Code :
Phone (Home): Phone (Work):
Email Address:
Local Council (see below):
School District:
School:
Position:
Please check:
New Member Renewal

Check Date: Amount: $
Credit Card Date: Amount: $ Visa
MasterCard Discover American Express Card #: code
Expiration Date: Signature:

Please Indicate: Classroom Teacher or Other position:

Elementary Title I/Special Ed
Middle School/Junior High Administration
Secondary Other:
COMBINED Local Council/State Memberships (Local Council Dues are included in the $25 per year)
Capital (40100) Mid-Valley (40450) Rogue Valley (40800) Vineyard Valleys(40950)
Driftwood (40200) Mount Hood Sunset (40860)  
Emerald Empire (40300) Mt. Valleys (40500) Three Sisters (40900)  
Mid-Columbia (40400) Portland (40700) Umpqua (40925)