ADMINISTRATORS' ROUND TABLE OF
WESTERN ILLINOIS
MEMBERSHIP APPLICATION FORM
Name: _________________________________________________________
Position: _______________________________________________________
School: ________________________________________________________
School Address: _________________________________________________
City: __________________________ State: _______ Zip Code: _________
E-mail: ________________________________________________________
Membership shall be limited to superintendents, assistant superintendents,
administrative assistants, elementary and/or secondary school principals, college
instructors and administrators in teacher-education programs, superintendents and
assistant superintendents of educational service regions, and supervisors and other
members of the professional staff of the State Board of Education.
Regular Membership Fee - $35.00
Retired Persons Membership Fee - $5.00
Please send this form along with a check to:
Administrators’ Round Table
Educational Leadership Department
Horrabin Hall 115
Western Illinois University
Macomb, IL 61455
OR
Email this form to educationalleadership@wiu.edu
followed by payment sent to the above address.
*Please save the document after entering your information before attaching to
email to ensure data transfer.