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Membership Application
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Member Type: or Last Name: First Name: Middle Name: Title: Home Email: Cell Phone: Home Address: City: State: Zip: Birth Month: Birth Day: Which of the following
best represents your
racial or ethnic
heritage?
Choose all that apply.






Position: School: Office Telephone: Office Email: District/Employer: School/Dist Address: City: State: Zip:
Note: Your information will not be shared with individuals or organizations at any time and will be used for KASA purposes only. This information also enables us to contact you in the event of an emergency.
Do you prefer that we mail your KASA materials to your home or to your office?
Text Message Communication
If renewing, were you a member last year?
How did you hear about KASA?
If you chose "Word of Mouth": Please list the name of the person who referred you:
If you chose "Other": Please specify how you heard about us:

KASA Membership Categories & Annual Dues Rate Schedule (Choose One):

Professional Member -- Annual Salary x 0.0032:
Eligible to purchase Professional Liability Insurance ( $107 annually )
Professional Lifetime Member -- Annual Salary x 0.0052:
One-time Payment; must be paid in lump sum
School leader assigned administrative/supervisory duties at the local school or district level; a vocational school administrator; an employee of a university or college who trains teachers and administrators; an employee of the Kentucky Department of Education; or an employee of other state education interest groups, commissions, and councils.
Enter your annual salary in the Members Dues Worksheet for dues calculation.
Premier Member -- Annual Salary x 0.0052:
Includes liability insurance
Premier Lifetime Member -- Annual Salary x 0.0082:
One-time Payment; must be paid in lump sum - includes liability insurance
School leader assigned administrative/supervisory duties at the local school or district level; a vocational school administrator; an employee of a university or college who trains teachers and administrators; an employee of the Kentucky Department of Education; or an employee of other state education interest groups, commissions, and councils.
Enter your annual salary in the Members Dues Worksheet for dues calculation.
Associate Member -- $89:
Designed for teachers, librarians, college/university professors and classified employees of a school district or other education group.
Ineligible to serve on the board or committees, vote or receive legal funds
Emeritus Member -- $59:
Available to retired school administrators not working in schools or education agencies and who have been a member of KASA for five consecutive years.
Ineligible to receive legal funds or enroll in the liability insurance program

Member Dues Worksheet

(Note: Do not use commas or periods when entering numerical amounts.)

KASA Affiliate Membership Categories

( Note: As a member of KASA, we encourage you to join AASA. KASA will submit your membership information and payment to AASA on your behalf. )

$107
(Fee Disclosure: Please be advised that the $107 insurance cost represents a $46premium, $4.41 state tax fee, and $56.59 policy plan management fee.)
(* Optional coverage, MUST BE PAID IN LUMP SUM. Cannot be paid through payroll deduction, must be paid by check OR credit card only. Available to KASA members only.)
Required Legal Notice -- Please Read. KASA dues may be partially deductible as a business expense. KASA estimates that 90% of your dues are deductible. 10% supports KASA’s advocacy activities which are not deductible.
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Cancellation Policy Membership automatically renews each year unless written cancellation request received for membership termination. For cancellations that occur during the membership year, member will be invoiced for the portion of the year in which benefits were received.
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Dues Payment Options

Option 1: Direct Pay Method (payment in one lump sum)




My school district has issued PO # for items listed above.

Option 2: Automatic Payroll Authorization Deduction Method (APA) for KASA & Affiliate Membership Dues
( NOTE: Available for Professional, Premier, and Associate only )


Note: If electing this option, please mail paper copy to KASA, 87 C. Michael Davenport Blvd., Frankfort, KY 40601.

Choose Your District:
( Note: If your district is not listed, it is not participating in the APA program at this time. )

Option 3: ACH ( Electronic Banking ) for KASA & Affiliate Membership Dues