School Developer Membership Application 2015-16 School Developer Application Member InformationName* First Last Your Email* Enter Email Confirm Email Title*Non-profit Name*Proposed School Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone*FaxSchool Email Enter Email Confirm Email School Enrollment Estimate*Website Opening Year (desired)*Grades Served*School Contact Name* First Last Title/Position*Phone*Email* Enter Email Confirm Email Charter School Board Members and Positions*Please enter a full current board list, including position and email address - one per line (e.g. Johnny Appleseed, Board President, email@example.com) 2015-16 Board Meeting Schedule*Member DuesApproved charter developer member dues are a flat fee of $750. Membership is active until your school opens or for a maximum of two years. Non-approved charter developer member dues are a flat fee of $250. When and if schools gain approval, schools can choose to move into the Approved charter developer membership category.Membership Type*Approved - flat fee of $750Non-approved - flat fee of $250Please make checks payable to the “Louisiana Association of Public Charter Schools.” Payment Mailing Address: Louisiana Association of Public Charter Schools 1555 Poydras Street, 7th Floor New Orleans, LA 70112Additional School ContactsSubscribe additional school members to Association communications (make sure to include your Business / Office Manager, Board President, and Instructional Leader/Lead Teacher). If you would like to subscribe your whole staff and board, enter their names, positions and email addresses in the text area provided below.Business/Operations Manager Name First Last Business/Operations Manager Email Enter Email Confirm Email Board President Name First Last Board President Position/TitleBoard President Email Enter Email Confirm Email Instructional Leader/Lead Teacher Name First Last Instructional Leader/Lead Teacher Position/TitleInstructional Leader/Lead Teacher Email Enter Email Confirm Email Additional Subscribers For more information on the specific services available to Association members, please explore our website. The Association reserves the right to deny or revoke membership at its sole discretion.Quality CommitmentAs an authorized party to sign on behalf of the school named above, I agree that the representations on this document are valid and true. The school named above wishes to join the Louisiana Association of Public Charter Schools. I understand that the LAPCS reserves the right to revoke membership at any time.Authorized Signature* Date* PhoneThis field is for validation purposes and should be left unchanged.