Public Membership Application Form Survey

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Please submit this form for review and consideration for Public Membership by the FGNA Board of Directors. A response can be expected to be received within thirty (30) days of this completed application. A One-Time Membership Fee of $50 USD will be due upon notification of your approved application.

Membership is available to any person who is supportive of FGNA, either as a financial donor, or by providing volunteer services to the organization. Membership is subject to approval by the FGNA Board of Directors, and must be ineligible for any other membership category. This category of membership does not include Certification or use of FGNA® Service Marks or the right to practice as a Feldenkrais practitioner or ATM teacher, and does not imply being a Professional Member. Public members have no voting rights.

I certify I meet the above criteria for becoming a Public Member:

1.	Name:*

2.	Occupation:*

3.	Mailing Address:*

4.	Contact Phone:*

5.	Mobile Phone:

6.	Email:*

7.	Reasons for applying for FGNA Public Membership:*

8.	Volunteer skills I am interested in sharing with FGNA:*

9.	Approximate volunteer hours I can share with FGNA:

10.	Other Organizations I am personally involved with:

By providing my mailing and email addresses, I agree to receive communications from FGNA including: communications regarding my membership, announcements, newsletters, learning opportunities, and publications. FGNA agrees to not sell my personal information without obtaining prior permission.

I DECLARE THE INFORMATION I AM PROVIDING IS TRUE. I AGREE TO ABIDE BY AND SUPPORT THE MISSION, BYLAWS, AND POLICIES OF FGNA.

11.	Signature (please type your full name which will act as your signature):*

12.	Date:*
	mm/dd/yyyy