Membership Application

Welcome to the Parrot Head Club of Eastern Massachusetts, Inc. !  Please take a moment to complete this application for our database.  Stop and open another Corona about halfway through (21 and over only); your answers will be more interesting that way!

* Print this page and send it to the address listed below.
TODAY’S DATE:  
NAME:  
NAME (2):  
STREET:  
CITY:  
STATE:                                       ZIP:
E-MAIL:  
E-MAIL (2):  
PHONE NUMBER: (              )
BIRTHDAY:  
BIRTHDAY (2):  
AFFILIATIONS
/SPECIAL SKILLS:		  

Can we contact you to help out at club  events?

    YES       NO 

The activities I am interested in are:  
   
   
My favorite Jimmy Buffett song is:  
And here’s why:  
   
   
The closest I came to meeting Jimmy was:  
   
   
   
For family memberships only: 
PARAKEET NAME(S)  
AND BIRTHDAY(S):  
   
   
   
 
Membership entitles you to our monthly newsletter, The Maņana Times, which includes information regarding our regional and statewide phlockings, community events, special discounts, VIP passes, and much more!  

Membership dues are: 
$20 Single membership 
$25 Couple / Family membership  

Send your check or money order payable to:

PHCOEM, Inc. 
P.O. Box 508, Milton, MA 02186

 Special Olympics 
An active sponsor of the 
Massachusetts Special Olympics.