H.E.A.R.T.S.Last Name: ____________________________
HEARTS 2007– 2008 Membership Registration
Membership in HEARTS runs from
Family Information
Birthdays and Anniversary are requested only as a courtesy so others may send you greetings
and well wishes. Please provide only month/day.
Last Name: _________________________________ # Years Homeschooling: __________
Husband: ___________________________________ Birthday _____/_____ (month/day)
Wife:_______________________________________ Birthday _____/_____ Anniversary _____/_____
Street Address: ___________________________________________________________________________________________
City: __________________________________ Zip: _____________ Phone:______________________________ ¨ Unlisted
E-mail: ___________________________________________________________ Contact Preference: ¨ E-mail ¨ Phone
Who referred you to or how did you hear about HEARTS.? ________________________________________________________
What branch of the service are you or your spouse a member of or retired from?___________________________________
Do you want your children’s info printed in directory? ¨ Yes ¨ No If yes, please provide information below
Child’s Name Birthdate Child’s Name Birthdate
_________________________________ ____/____/___ ______________________________ ____/____/___
_________________________________ ____/____/___ ______________________________ ____/____/___
_________________________________ ____/____/___ ______________________________ ____/____/___
_________________________________ ____/____/___ ______________________________ ____/____/___
_________________________________ ____/____/___ ______________________________ ____/____/___
Waiver of Liability
The activities and field trips planned by H.E.A.R.T.S. members and/or leadership are for the purpose of helping with the education of children in H.E.A.R.T.S. families. It is our desire to promote safety and wellness in all activities. However, accidents happen that cannot be helped. Therefore, for your child(ren) to participate in any of H.E.A.R.T.S. activities and/or field trips, you must sign the waiver below.
I/we ________________________________________ shall hold harmless all parties connected with the operation of the H.E.A.R.T.S. Home School Support Group, to include those serving in group leadership and those leading field trips or other activities as well as any facilities used for meetings or activities, from any claim of/for injury or loss which might result from participation by any or all of my/our family members and myself, in any of the meetings, activities or events.
Parent/Guardian: _______________________________________________________________ Date: ___________________
(signature of both parents/guardians is required if both have joint custody in cases of divorce)
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