Existing CCIS member information update

*Please fill out the following form to update your membership information.

Date:

Reason for update: Correction ChangeAddition Other:

Last Name:

First Name:

Position: Teacher Principal Counselor Administrator Other:

School District /

Organization:

Grade Level:

Charter School Home-Based I.S. Community School

Other:

Is your school WASC accredited? Yes No

School Name:

Street Address:

City:

Zip:

School Phone:

School Fax:

County:

CCIS Region:

Email Address:

Check here to exclude your

information from the internet:

Other/Comments: