Institutional Membership Sign-up Form - Gold Level

Institution Information

School Name:

Address:

City:

State:

ZIP Code:

Principal's First Name:

Principal's Last Name:

Principal's Email:

Grade Levels:

Enrollment:

District:

District Superintendent's First Name:

Last Name:

Superintendent's Email:

Type of Membership

$1500 Gold (Gold Level Membership includes three on-site trainings: AIMS designated topic, one chosen from AIMS’ list, and one of your choice and six complimentary memberships.)

Please designate your complimentary memberships

Member One

First Name:

Middle Initial:

Last Name:

Position:

Grade Level:

Member Two

First Name:

Middle Initial:

Last Name:

Position:

Grade Level:

Member Three

First Name:

Middle Initial:

Last Name:

Position:

Grade Level:

Member Four

First Name:

Middle Initial:

Last Name:

Position:

Grade Level:

Member Five

First Name:

Middle Initial:

Last Name:

Position:

Grade Level:

Member Six

First Name:

Middle Initial:

Last Name:

Position:

Grade Level:

Required Official Signatures

Contact Person __________________________ Date _______________
Principal _______________________________ Date _______________
Superintendent __________________________ Date _______________

Billing Information

Payment options:

Address if different from above:

Address:

City:

State:

ZIP Code:

When you complete the form you will be redirected to an online payment page. If you would rather not pay online, please print this form (by clicking the printer icon below) and mail it to AIMS with your payment.

AIMS
University of Illinois Champaign-Urbana
510 Devonshire Drive
Champaign, IL 61820

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Important Dates

Membership - School Form