Bulk Student Membership Purchase Order

Institutions wishing to purchase memberships in bulk for their new or continuing students may do so at a rate of $25 per student member (regardless of the rate of compensation for students/graduate students). Credit card payment is due upon form completion. A receipt will automatically be emailed to you.

This form is intended for purchase of 5-30 student memberships. Please contact lsa@lsadc.org if you are registering more than 30 students or have questions about a small student group.

Primary Contact Information

Please provide the requested information for the person who will serve as the primary contact for your group membership. The primary contact will serve as the main point of communication for any questions related to this form submission or payment.

Question Title

1. Primary Contact First Name: (Required.)

Question Title

2. Primary Contact Last Name: (Required.)

Question Title

3. Primary Contact Job Title: (Required.)

Question Title

4. Primary Contact Email Address: (Required.)

Question Title

5. Primary Contact Phone
000-000-0000 (Required.)

Question Title

6. Organization Name: (Required.)

Student Membership Information

Question Title

7. How many student memberships are you purchasing?
This form is intended for purchase of 5-30 student memberships. Please contact lsa@lsadc.org if you are registering more than 10 students or have questions about a small student group. (Required.)

You’ll enter payment info after the survey.

Please provide the requested information on behalf of all students included in the membership purchase. The number of students listed below should match the number indicated above. When finished, scroll to the bottom of the page to pay by credit card.

Question Title

8. Student 1: (Required.)

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

9. Student 2: (Required.)

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

10. Student 3: (Required.)

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

11. Student 4: (Required.)

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

12. Student 5: (Required.)

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

13. Student 6:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

14. Student 7:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

15. Student 8:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

16. Student 9:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

17. Student 10:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

18. Student 11:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

19. Student 12:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

20. Student 13:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

21. Student 14:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

22. Student 15:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

23. Student 16:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

24. Student 17:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

25. Student 18:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

26. Student 19:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

27. Student 20:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

28. Student 21:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

29. Student 22:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

30. Student 23:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

31. Student 24:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

32. Student 25:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

33. Student 26:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

34. Student 27:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

35. Student 28:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

36. Student 29:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)

Question Title

37. Student 30:

First Name:

Last Name:

Email Address:

Is this student currently or previously a member of the LSA? (Y/N)