We are a not for profit social club involved in supporting local charities
and environmental projects…and, we have PHUN! 

Applicant #1: ______________________________________________
Address: __________________________________________________
City, State, Zip: ____________________________________________
Email: ____________________________________________________
Phone(s): _________________________________________________
Birth Date: ___________________ Today’s Date: ________________ 

Applicant #2: ______________________________________________
Address: __________________________________________________
City, State, Zip: ____________________________________________
Email: ____________________________________________________
Phone(s): _________________________________________________
Birth Date: __________________ Today’s Date: _________________ 

Names and Birth Dates of Keets (dependent little ParrotHeads!)

#1: ______________________________________________________

#2: ______________________________________________________

(If there are more, list them on back, please!)

Annual membership dues are $25.00 for single (over 21 yrs.) or $35.00
family (adults & dependents). Dues are pro-rated the first year to help
align annual billing, which is due in October. If you join in the following
months, please pay as noted:

Membership fee is not tax deductible. 

I/We are interested in the following committees/activities: (Check all that apply!)

___ Membership ___ Social ___ Tickets ___ Newsletter ___ Web Page 
___ Advertising/P.R. ___ Merchandise ___ Charitable Events

Please mail this application along with your check to:

Parrot Heads in Michiana
P. O. Box 563
Mishawaka, IN  46544

email: info@parrotheadsinmichiana.org