Membership Form Name: ________________________ Today's Date:____________ Address: _______________ State: _________Zip: ______________ Home ph#: __________ Birth mm/dd ______ Work ph#: __________ Cell Phone ______ Fax: ____ Screen Name __________ Email: _____________ Occupation: ____________________________ Hobbies& Interests ____________________ Nick Name: _______ Marital status_____ Spouse's name______ Kids Names / ages ___________________________ I am interested in helping the following activities: (Please circle all that apply) Anything, ( Put me where you need me ) Fund Raising Community Service Newsletter How did you hear about the club / referred by ?_____________ If we do a phone list or directory, is it okay to print your name/address/email/phone? YES NO We'd Like to hear about your adventures: Do you have a favorite Jimmy Buffett or Coral Reefer Story, most memorable or interesting concert, Special souvenir furthest traveled, or large number of concerts attended to tell us about _____________________________ _______________________________ _______________________________ ************************ The Obligatory Fine Print * Each member of the Cincinnati PHC is responsible for his or her own actions and behavior whether negative or positive. * Membership in the club does not give the member permission to use Jimmy Buffett's name, song titles,lyrics, names of business or other trademarked, copyrighted, or reserved material owned by Jimmy Buffett. Nor can any member use the logo of the Cincinnati Parrot Head Club, Inc., or Parrot Heads in Paradise, Inc. ** Annual dues are $25/person- due yearly at the beginning of each year Make checks payable to: Cincinnati Parrot Head Club MAIL completed form and check to: Chip Simpson, Treasurer, Cincinnati PHC 6 Louis Circle Cold Spring, KY 41076 or better yet, bring them both with you, to the next meeting............. These dues are not deductible as charitable donation for federal, state or local taxes |
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