PROGRAM PROVIDERS MEMBERSHIPA Program Providers Membership is granted to an organization, company or entity which provides enrichment classes or programs to children/minors. Please fill out the information requested below. Once your application has been processed, your membership will be active. (Please allow 2 weeks for processing). Fields marked with a * are required. *Name of Organization: *Full Address: *City: *State: *Zip: *Phone Number: *Fax: *Company email: *Website:
*Please mark the appropriate box or boxes which best describe your organization:
Enrichment Company
Summer Day Camp Park & Rec Department Private Studio (Dance, Karate, Arts, etc.) Community Center Daycare Center City-operated Enrichment Program School Aftercare/Yard Program YMCA Other
If you marked “Other”, please describe:
* Contact Person: First name Last name *Position:
Payment Information To pay by credit card please fill out below. If you are paying by check, please print out this page with the completed information and include a check in the amount of $78 made payable to NETA, Inc. Mail to: NETA Memberships, 13428 Maxella Ave. #436, Marina Del Rey, CA 90292. Once your application and check have been processed, NETA will mail you your Associates Membership card and password. Type of Credit Card: Visa MasterCard * Card Holder’s Name: * Billing Address:
* Card Number: *Exp. Date: CV2 #:
Terms of Agreement This Program Providers Membership is valid for one year from the date of processing and can be renewed annually. This is a membership only and the National Enrichment Teachers Association, Inc. does not endorse, accredit, certify or guarantee the work of the bearer of this membership. Deliberate misuse of this membership (i.e. fraud, misrepresentation, solicitation for private gain, etc.) is prohibited and can result in the suspension of and/or revocation of membership privileges. *Initials: *Date:
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