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NIAGARA COUNTY COMMUNITY COLLEGE ADVOCATES FOR STUDENT WITH DISABILITIES CLUB

MEMBERSHIP INFORMATION FORM


AFFIRMATIVE ACTION / EQUAL OPPORTUNITY ORGANIZATION FALL SPRING 20________

Please Fill Out All Fields On This Form. Please Use Working, Reachable Numbers For Your Contact Information. Name: Student ID: * @ E-Mail Address: Date Of Birth: (So We Can Sing Happy Birthday) Student Status: (Circle One) Curriculum: Returning Student Next Semester?? Interested In An E-Board Position?? If Yes Check All That Apply: (Must Be A Current Matriculated NCCC Student And Have & Maintain A 2.50 GPA) Freshman / Sophomore / Club Alumni Anticipated Grad Date: STUDENT INFORMATION Phone Number: Alternate Phone:

Co-Captain (2 Positions) Publicity Representative

Secretary

Treasurer

DISCLAIMER, CONSENT, AND SIGNATURES I certify all information on this form is correct. I understand that the information I am voluntarily providing is CONFIDENTIAL and will NOT be disclosed to anyone other than the E-Board Members (Officers) of ASD Club, and the Student Life Office, (for the purpose of communication) without my written consent.

I hereby consent to being photographed / videotaped at events and having any photographs and / or videos of myself be used ONLY for brochures, flyers, and having such materials posted on social media sites that are directly linked to the NCCC ASD Club. (Ex: Having a picture of you put on our clubs FB Page). I hereby consent to disclose my Date of Birth to the ENTIRE ASD Club for the purpose of singing to me on my birthday.

All information provided is protected under the NASW Code Of Ethics Confidentiality Clause. I understand that any anytime I may, in writing, withdraw my consent for ANY of the above items. Member Signature: Date: AVAILABILITY ( For Scheduling Meetings & Events) Monday Tuesday Wednesday Thursday To: From: Why Do You Want To Join The NCCC ASD Club And What Contributions Can You Make To The Club???

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