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MEMBERSHIP APPLICATION
[ ] New member(s) [ ] Renewal
ADULT
MEMBERS:
CAPTAIN:______________________ 1STMATE:________________________
PARAKEETS (kids):
KEET #1__________________ KEET #2__________________
ADDRESS:______________________________________________________
CITY: __________________________ST: ____ ZIP: __________
PHONE: H:______________________C:___________________
EMAIL: ___________________________ EMAIL: ___________________________
BIRTHDAYS: CAPTAIN: ___________ 1ST MATE:___________
KEET
1:_____________ 2: __________________
FAVORITE SONG:____________________________________________________
COMMUNITY INTEREST:_______________________________________________
CLUB INTEREST:_____________________________________________________
OCCUPATION:________________________________________________________
I have read & understand the Phip,Inc/PHPB,Inc.
Disclaimer/Code of Conduct: ____ (initials)
Yearly Membership Dues
$20 single / $30 couple /$1 per child (birth to 17 yrs)
Send your check payable to:
PHPB, Inc
P.O. Box 21084
West Palm Beach, FL 33416-1084
PHPB, Inc / OOSK
Is a sanctioned chapter of PHIP, Inc
Parrot Heads in Paradise and the
OPHicial ParrotHead Club of Palm
Beach Country, FL
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