Bluegrass District Dietetic Association

Your Link To Nutrition And Health

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BGDDA Membership

Register online for the 2011-2012 year!  Simply fill out the registration form below and click submit.  Also, click "buy now" on the paypal button which allows you to pay securely with a credit card ($1.50 convenience charge applies).  If you prefer the mail-in form, click on the link below to download the printable application.

If you are interested in joining the Bluegrass District of the Kentucky Dietetic Association, applications for the 2011-2012 membership term are due by August 17, 2011.
BGDDA Membership Application 2011-2012
2011-2012 Membership Application (Please complete form, submit and pay below using the paypal button that applies to you.)
First Name
Last Name
Middle Initial
Credentials
ADA Number
Preferred Mailing Location (Home, Work, or School)
Address Line 1
Address Line 2
City
State
Zip Code
Preferred Phone (Work, Home, or Cell)
Work Phone() -
Home Phone() -
Cell Phone() -
Pager
Fax() -
E-mail Address
Position Title
Place of Employment
Please List any Dietetic Practice Groups to Which You Belong:
Membership Type (Active, Student or Retired)
Please indicate the year you joined ADA as a member, and if associate or active.
Please indicate your age as <35, 35 or >35 (helps to determine award qualifications)
Would you be willing to have your name and address as part of a mailing list release to other professional organizations?
Would you be willing to have your name and address as part of a mailing list released to legislators who may wish to advise you of their stand on nutrition issues?
Would you be willing to have your name and contact information included in a media packet indicating willingness to respresent BGDDA as a nutrition expert on radio and television? If yes, please indicate specific topics.
Would you be willing to have your name listed on the Speaker's Bureau for BGDDA and other organizations? If yes, on what topics would you be willing to speak?
Please list any committes you are willing to serve this year for BGDDA (Options: Awards/Honors, By-Laws, Career Guidance, Continuing Education, February Seminar, National Nutrition Month, Legislation/Nutrition Services Payment Systems, Marketing/PR, Publications & Records Directory, Web Page)
Please list which elected district positions you would be willing to serve as next year (Options: President-Elect, Secretary, Treasurer, Nominating Committee)
We want our programs to be interesting and educational. What topics/speakers would you suggest for next year?
Active Membership (New or Renewal)
$26.50
Student Membership
$11.50
Retired Membership
$16.50