SCIRA Membership Application

For your convenience, you may fill out this application form on-screen and then print it. Or you may leave it blank, print it, and complete the form using black ink. Your completed membership application should accompany a check made payable to your local council and then mailed to your local council (see Local Council page for addresses).

Membership is effective July 1 through June 30 of each calendar year.

	Type on-screen or print a blank copy to complete by hand.
	This is a NEW MEMBERSHIP This is a MEMBERSHIP RENEWAL.
	If renewing your membership, please provide your SCIRA member number. My SCIRA Member # is:
Membership Level (check one)	One-Year SCIRA Membership -- $10 One-Year Student SCIRA Membership -- $5
	Fill in all blanks as completely as possible.
First Name	Middle Initial
Last Name
First Name for Name Tag
Home Mailing Address
City	State Zip
Home Phone
School NAME
Email
School Phone
School District
Local Council Affiliation
Indicate your primary position (check one)	Elementary School Administration Media Specialist Student Middle/Junior HS Higher Ed Adult Literacy Other:
Are you a member of IRA? If so, please provide your IRA member number here.

Once you have completed this form, choose PRINT from your browser window to print this form.
CHECK THE PRINT-OUT to make sure all information appears correctly.
Then mail the printed form with your check (made payable to your Local Council) to your Local Council office.

The RESET button will automatically remove all information from the form.