HAHPERD Membership Application

Personal Information:

Name:
Address:
City: State: Zip:
Home Phone: Mobile:
Pager: Email:


School Information:

School/District:
School/Business Address:
City: State: Zip:
School/Business Phone: ext.
Email:

Please Check Your Choice of Memebership:
Life $100.00 Regular $5.00    Contributing $10.00
Institutional $5.00    Associative $3.0 0    Student $2.00

Please submit this form and then print it to mail.
Please include your check when mailing this form to:
HAHPERD
Att. Barbara Perry, Treasurer
2720 Kamanaiki Street
Honolulu, HI 96819
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For HAHPERD use only
Received:____________________________________ Membership Card Sent:__________________________________

TREASURER Receipt #:__________________________________ Recorded:___________________________________