I.  CONTACT INFORMATION:              

Last Name:		First Name:	MI:
Organization:			Date:
Mailing Address:
Street Address (if different)
City:		State:	Zip:
County:	Select County Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia De Soto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Saint Johns Saint Lucie Santa Rosa Sarasota Seminole Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington	Telephone:	Fax:
E-Mail:

Your e-mail address is very important to us and is one of the primary methods we use to communicate with our members.

Yes No   I would like to join the Member Forum (E-mail required)  The Member Forum is used for members to share ideas and get feedback from other Forum subscribers.  You will receive e-mail from other members if you change your selection to "yes."

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II. MEMBERSHIP CATEGORIES: .                                                                                                        

Individual Membership

A.  Individual Professional Guardian Membership:  individuals who serve as court appointed professional guardians registered with the Statewide Public Guardianship Office. [SPGO Registration number ]   If no SPGO Registration number is listed above, please indicate if SPGO registration is pending or you are unregistered.	$90.00
B.  Individual Family/Volunteer Guardian Membership:  family members or friends who serve as a guardian for an individual	$50.00
C.  Individual Affiliated Professional Membership:  professional individuals other than guardians who participate in activities that enhance the role of a guardian, including individual case managers, nurses, physicians, attorneys, social workers and others.	$90.00

Organization Membership

D.  Organization Professional Membership: organizations that serve as guardians or participate in activities that enhance the role of a guardian.  This includes Office of Public Guardian, and religious organization guardians as well as social service agencies, law firms, service provider agencies, assisted living facilities, skilled nursing facilities, court personnel, home health care agencies and others.  The membership is in the organization’s name and two individuals are designated by the organization as representatives.  Name of second representative

$ 180.00

II.  TOTAL (Enter Your Total)

$

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III.  CHAPTER MEMBERSHIP             

FSGA encourages members to join a local chapter for increased networking opportunities and great involvement. FSGA state organization membership required. Corporate associate dues are indicated in parentheses. This membership fee is in addition to the FSGA membership fee and will be sent to the local Chapter.               

IV.  MEMBER DESIGNATION

Please indicate your membership designation for our online membership directory – one listing is free with membership, each additional designation listing

$25.00

Assisted Living Facility	Attorney	Care Manager
Community Services	Court Personnel	Fiduciary (e.g.: Trustee)
Financial Services	Guardian (Family)	Guardian (Corporate/OPG)
Guardian (Individual Professional)	Hospital/Medical Services	Paralegal
Skilled Nursing Facility	Other

(URL Display name ) 

IV.  TOTAL (Enter Your Total)

$

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V.  ADDITIONAL CONTRIBUTION

Please indicate if you would like to make an additional contribution (optional). Donors will be recognized for their support on the FSGA website:

VI.  TOTAL DUE

$

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FSGA Refund Policy

Dues for membership in the Florida State Guardianship Association (FSGA) are not normally refundable. Organizational members may change the names of their representatives by writing to the Executive Director. Individual memberships are not transferable. Request for exception to this policy may be made to the Board of Directors of FSGA
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