MEMBERSHIP APPLICATION/RENEWAL
FORM
Please
download and/or print, fill out, and mail to the address at the end of this
form.
(Check or circle
the correct category)
NEW APPLICATION
RENEWAL
NAME ____ __________________________________________________________
Title
First
Middle
Last
Appel
NON-NATIVE
DESCENDANT OF __________________________________
CITIZEN OF
__________________________________
ADDRESS __________________________________________________
street
__________________________________________________
city
state zip
HOME PHONE __________________ FAX ______________________
EMAIL ADDRESS: ______________________________
WEBSITE: ______________________________
OFFICE
__________________________________________________
__________________________________________________
city
state zip
HOME PHONE __________________ FAX ______________________
DATE OF BIRTH (Month/Day/Year) ___ / ___ / ________
BIRTH PLACE _____________________________________
NOTE:
This information is used for member ID purposes only. Only the month and day of
birth are published in the
Membership Category
Please check or circle the category which applies
to you.
REGULAR
(Native and non-Native) - Dues are $40.00 per year
STUDENT (Native and
non-Native - Dues are $25.00 per year
SENIOR (50+, Native and
non-Native) - Dues are $25.00 per year
INDIVIDUAL
(Publisher/Literary Agent/Publicist)- Dues are $50.00 per year
ORGANIZATION
(Library/Educational Institution) - Dues are $75.00 per year
SPONSOR ($100+)
PATRON ($500+)
Writing - Storytelling - Speaking
Style & Experience
In the following section,
please identify your level of experience.
Beginning level is for those
who have 0-4 published writings and/or 0-6 public storytellings/speaking
engagements.
Emerging
writers/storytellers have 5-15 published writings and/or 7-30 public storytellings/speaking engagements.
Professional
level is for those with 16 or more published writings and/or 31 or more public storytellings/speaking engagements.
Writing Style and Experience
Please check or circle the appropriate choice.
CREATIVE - (poetry, fiction, non-fiction, essay, novel,
novella, monograph, etc.)
Beginning
Emerging
Professional
None
ACADEMIC - (thesis, dissertation, research, evaluation,
project papers, etc.)
Beginning
Emerging
Professional
None
TECHNICAL - (reports, grant proposals, reference works,
manuals, etc.)
Beginning
Emerging
Professional
None
SPECIALTY - (journalism, play/film/TV scriptwriting,
song/lyrics, etc.)
Beginning
Emerging
Professional
None
Storytelling/Speaking Style and Experience
TRADITIONAL
STORYTELLING
Beginning
Emerging
Professional
None
CONTEMPORARY STORYTELLING
Beginning
Emerging
Professional
None
READINGS/PERFORMANCE
Beginning
Emerging
Professional
None
LECTURES/SPEAKING
Beginning
Emerging
Professional
None
PRESENTATIONS/EXHIBITIONS
Beginning
Emerging
Professional
None
Core Area Preferences
COMMUNITY CORE
Participate
at a physical site in
Organize/conduct
at a physical site a
Organize/Conduct
a Wordcraft Circle On-Line (Internet) writing
workshop, chat-room, etc.
MENTORING CORE
Apprentice -
work with an established Native writer/storyteller for at least one year
ON-LINE (Internet/email).
Apprentice -
work with an established Native writer/storyteller for at least one year
OFF-LINE (mail/phone)
PROFESSIONAL CORE
Available for book
signings.
Available
for speaking engagements.
Available to write
reviews (books, essays, etc.)
Education
High School ________________________________________ Year
Graduated ______
Location ________________________________________
College/University __________________________________
Location __________________________________________
Major _______________________________ Year Graduated __________
Degree ______
College/University __________________________________
Location __________________________________________
Major _______________________________ Year
Graduated __________ Degree ______
College/University __________________________________
Location __________________________________________
Major _______________________________ Year
Graduated __________ Degree ______
Honors & Awards
Please check the
box if you are a Wordcraft Circle Honors and/or
Awards Recipient.
Please state the honor and/or award (i.e., Wordcrafter
of the Year) and the year received (i.e., 1996)
Please list other
(non-Wordcraft) honors and awards you have received.
Published Writings
Please list
your published writings
(Type [poetry/essay/short story/etc.], Title, Publisher, Date Published,
ISBN/ISSN).
Public Storytellings/Speaking
Please list
your public storytellings/speakings/readings/performances/lectures/presentations
(Type [storytelling etc.], host/sponsor, date of event, city/state]).
Biographical Profile
Please write a
brief biographical profile.
Why Wordcraft
Circle?
Please state
why you are applying to become a member of
What will you be able to contribute toward expanding the
Additional Documents
Your application
will be processed when
- a recent photo of you
- a sample of your writings
- a check/money order for the dues amount.
Note:
Credit card payments are not accepted at this time.
Please send check/money
order (made payable to "
|
Dr.
Kimberly Roppolo Department of English |
(or) |
|
Click Here To Send Photo (.jpg file) And Writing
Sample
Membership Agreement
By submitting this
membership application, I agree to abide by the Bylaws and Code of Ethics
of Wordcraft Circle of Native Writers and
Storytellers.
Signature:
______________________________________
Updated: 01/28/2010
contact: Robert Nelson