Massachusetts Adult Day Services Association

Membership Application

Parent Company: ___________________________________________________________

ADH Program’s Name: _____________________________________________________

Director: _________________________________________________________________

Address: _________________________________________________________________

City: ____________________________ State: _____   Zip Code: ____________________

Phone: ___________________________  Fax: ___________________________________

Email: ___________________________________________________________________

Webpage: ________________________________________________________________

Capacity #_____ (licensed capacity)

Annual Dues for the membership year September 1, 2010 - August 31, 2011

Capacity combined for all centers within your agency
 

Dues calculation                                       Amount due 

                                                              
_____________________________________________________________________________________________________________________________________      

Your annual Dues are based on the aggregate capacity of all your programs. In order to be represented accurately,
please list all affiliated ADHCs along with Director and capacity of each facility.  (See 2^nd page)

Slots  _________                     Dues $ _________

______________________­­­­­­­­­­­­_______________________     ________________________

Signature                                                                                                          Date

For Profit     Non-Profit

Please make checks payable to: MADSA
 

When submitting request for payment be sure you indicate our new address..
 

Mail to:                                   MADSA

                                                C/O Gardner VNA

                                                34 Pearly Lane

                                                Gardner, MA  01440

Affiliated  Adult Day Health Programs

1.

Facility:_______________________________________________________________

Director: ________________________________________________________________

Address:_______________________________________________________________

City: ____________________________ State: _____  Zip Code: ________________

Phone: ___________________________  Fax: _______________________________

Email: ________________________________________________________________

Capacity #_____ (licensed capacity)

2.

Facility:_______________________________________________________________

Director: ________________________________________________________________

Address: ______________________________________________________________

City: ____________________________ State: _____  Zip Code: ________________

Phone: ___________________________  Fax: _______________________________

Email: ________________________________________________________________

Capacity #_____ (licensed capacity)

3.

Facility:_______________________________________________________________

Director: ________________________________________________________________

Address: ______________________________________________________________

City: ____________________________ State: _____  Zip Code: ________________

Phone: ___________________________  Fax: _______________________________

Email: ________________________________________________________________

Capacity #_____ (licensed capacity)

***********Please feel free to duplicate should you need more space************