Membership Form

Family Membership Form

Please complete this form and submit it along with the $125.00 membership fee (August to August). You can pick up your membership cards on the first day of classes. If you have any questions you may contact HERC via e-mail.

Family Membership Form

Family Last Name (please state if child’s last name is different):(*)

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His First Name:

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Work Number:

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Cell Phone Number:

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Her First Name:

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Cell Phone Number:

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Work Phone:

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Home Address:(*)

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City:(*)

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State:(*)

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Zip:(*)

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Email Address(*)

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Email Address

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Other Memberships

HSLDA

CHEA

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School Name:

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Church Home:

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Please list any languages spoken other than English:

Student

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Father

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Mother

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Please list all children in your family (*Please indicate graduated, preschool or infant under grade level)

Child 1 Name(*)

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Date of Birth(*)

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Grade Level(*)

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Child 2 Name

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Date of Birth

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Grade Level

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Child 3 Name

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Date of Birth

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Grade Level

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Child 4 Name

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Date of Birth

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Grade Level

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Child 5 Name

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Date of Birth

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Grade Level

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Child 6 Name

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Date of Birth

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Grade Level

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Child 7

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Date of Birth

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Grade Level

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Child 8 Name

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Date of Birth

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Grade Level

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Child 9 Name

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Date of Birth

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Grade Level

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Child 10 Name

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Date of Birth

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Grade Level

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Child 11 Name

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Date of Birth

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Grade Level

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Child 12 Name

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Date of Birth

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Grade Level

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Payment Method

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Membership Fee

Membership Fee - $125.00 USD

Size of complimentary HERC membership t-shirt

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Any additional t-shirts

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Total

USD $0.00

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(*)

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