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PIRSA APPLICATION 2006 NAME _______________________________   INSTITUTION/AGENCY  ________________________________ MAILING ADDRESS  ___________________________________  DAYTIME PHONE _____________   FAX  ____________________  EMAIL ADDRESS  ____________________________________  YOUR POSITION (TITLE) ______________________________ DEMOGRAPHIC INFORMATION  Please Check --Optional Disclosure Gender________ Male          _______  Female  Disabled   ____ YES             _______ N)  Shirt Size (circle)       sm       xl       med       xxl  lg       xxxl Ethnicity  ____  African American   ____Asian American/ Pacific Islander ____  Caucasian   ____  Hispanic   ____ Native American   ____  Other  AREA OF EMPLOYEMENT      Please Check ___  College/University   ____  Community/Junior College ___ Correctional Facility  ____  Military  ___ Non-Profit Organization   ____ Recreation/Parks ___   YMCA/YWCA/JCC     ____  Other

REGISTRATION FEES    ____   STUDENT   ($15)   ____   PROFESSIONAL ($25)   DUE BY: SEPT. 25, 2006- Make checks Payable to PIRSA OR Attend the State Workshop and your conference will cover your membership dues. Send checks to:  Corey Shannon,  St Josephs University                     5600 City Ave. Philadelphia, PA 19131