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11/19/2008
Urbana, Illinois
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10/15/08
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Illinois Middle Grades Network - RENEWAL APPLICATION
Institution Information
School Name:
*
Address:
*
City:
*
State:
*
ZIP Code:
*
Principal's First Name:
*
Principal's Last Name:
*
Principal's Email:
*
Grade Levels:
Enrollment:
District Name:
District Address:
City:
State:
ZIP Code:
Other middle schools in district (please list):
Direct Superintendent's First Name:
Last Name:
Superintendent's Email:
Type of Membership
Membership Type:
*
Basic - $300
Bronze - $500
Silver - $1000
Gold - $1500
Member One
First Name:
Middle Initial:
Last Name:
Position:
Grade Level:
Subject:
Member Two
First Name:
Middle Initial:
Last Name:
Position:
Grade Level:
Subject:
Member Three
First Name:
Middle Initial:
Last Name:
Position:
Grade Level:
Subject:
Member Four
First Name:
Middle Initial:
Last Name:
Position:
Grade Level:
Subject:
Member Five
First Name:
Middle Initial:
Last Name:
Position:
Grade Level:
Subject:
Member Six
First Name:
Middle Initial:
Last Name:
Position:
Grade Level:
Subject:
Billing Information
Payment options:
Check enclosed with application _______________
Pay with Purchase Order _______________
Bill - School
Bill - District
Online
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
Answer:
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