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, 2007 – August 31, 2008

Capacity combined for all centers within your agency
 

Dues calculation                                       Amount due                                             

 

    0 – 24   600
  25 – 39 775
  40 – 59 1000
  60 – 85 1225
  86 – 110 1400
111 – 135 1500
136 – 175  1600
          175+ 1700

                                                              
_____________________________________________________________________________________________________________________________________      

 

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 2nd page)

 

Slots  _________                     Dues $ _________

 

______________________­­­­­­­­­­­­_______________________     ________________________

Signature                                                                                                          Date

 

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************