Georgia Association of Homes and Services for Children 

GAHSC 2008 MEMBERSHIP RENEWAL FORM
Please return renewal form by January 1, 2008

Information on Dues Structure:

GAHSC dues consist of .004 of the agency’s 2007 expenditure budget.  The following is an example of how to calculate your agency’s dues.

 $ 1,000,000          Agency Budget
  x         .004         Dues Factor of Budget
           4,000         Annual Membership Dues 

The minimum dues are $600 and the maximum dues are $7,500. 

Agency Name:   

1. My agency’s expenditure budget is $_______________________. 

2. My annual GAHSC dues are:  ____________________________ 

3. Please check your preferred method of payment: 

   One-time annual payment due by January 31, 2008.

    Semi-annual (twice a year) payments due by January 31 and June 30, 2008.

    Quarterly payments due by January 31, April 30, July 31 and October 31, 2008. 

4.   I certify that the above information is true, correct, and fully reflects our organization’s current annual budget and the full dues owed to the Georgia Association of Homes and Services for Children for the 2008 calendar year.  This completed renewal application form serves as our agency’s request for membership in GAHSC for the 2008 calendar year. 

_________________________                      ___________________

Director                                                           Date

Please also complete the following Provider Services Survey and return with your renewal.  

In each category listed below, please indicate the number of programs currently served by your agency.            

____CCI (Child Caring Institution)           

____CPA (Child Placing Agency)           

____OCCP (Outdoor Child Caring Program) 

____PRTF (Psychiatric Residential Treatment Facility) 

____Family and Community Supports 

____Medicaid - Core  

____Medicaid - IFI  

____Independent Living 

____Camp – Day or Summer 

34 Peachtree Street, NW, Suite 2230
Atlanta, Georgia 30303
404.572.6170