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Membership Form

Dues are based on number of consumers served. In keeping with APD policy, two children/CDC consumers equals one. Find your caseload size on the form and select that option to determine your dues.

* - Required Field
Name *
Agency Name
Number of SC's in Agency
Address *
City *
State *
Zip Code *
E-Mail *
Phone *
Provider Type
Dues
Payment Option
Areas Served
(hold down "Ctrl" and click to select multiple areas)
Years as SC
What Services do you provide?
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