Holland-America Club of Dallas (Renewal-) Membership Application Form 2007 / 2008

Yes, I / We would like to renew / join.

Fill in the information as you would like it to appear in the Holland-America Club Directory.
(orange fields are mandatory)

Name
(First): (Last): Speaks Dutch? Yes No

Spouse's Name
(First): (Last): Speaks Dutch? Yes No

Street Address:

City: State: Zip Code:

Phone: Mobile:

Hobbies / Interests
Member:

Spouse:  

E-mail:

Referred by:

Your Birthday: Spouse's Birthday:

Names of Children under 18:
 Birthday: Boy Girl
Birthday: Boy Girl
Birthday: Boy Girl
Birthday: Boy Girl
Birthday: Boy Girl

May we have permission to print the above information in our directory and use
the birth dates for Happy Birthday wishes in the Newsletter? Yes No

Membership Dues:
 Full Family Membership $45.00 - Single Membership $30.00
 Senior Membership (65+ couple) $35.00 - Newsletter Only $20.00

Please pay by check. We will provide the mailing address on the next page after you submit this application.

I, by submitting this form, do hereby declare that when I, my spouse and child(ren) will be participating in various activities of the H.A.C.
I assume all risks and hazards incidental thereto, but not limited to, transportation to and from said activities, and do hereby wave, release,
absolve, indemnify and agree to hold harmless the H.A.C., its officers and members from any claim arising out of injury during any activity
authorized by the H.A.C..

This agreement is effective from the date of submission and remains valid as long as you are a member of the Holland America Club of Dallas.

 

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