LeadingAge Minnesota - Student Membership Application

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	Student Membership

	This category of membership is for students of colleges and universities engaged in studies related to aging issues, healthcare administration, gerontology or occupations serving the field of older adult services.

Contact Information:*

First & Last Name:
Address:
City, State, Zip:
Phone:
Email:

Education Program Information:*

What college/university are you attending?
What education program/degree are you seeking?
What is your program completion/graduation date?

3.	How did you hear about LeadingAge Minnesota and what are your primary interests in membership?

4.	I am interested in career placement assistance.
	YesNo

	I understand that membership is conditional upon approval by the LeadingAge Minnesota Board of Directors.

5.	Electronic Signature* (Please type in your name)

	This category of membership provides full member benefits, excluding the ability to vote, hold office or serve as a Director. Questions Contact: LeadingAge Minnesota 3001 Broadway Street NE, Suite 300 Minneapolis, MN 55413 651.645.0002 (FAX) membership@leadingagemn.org