CPHC Membership Form (single payment revision)

On-line Membership Application

To apply for membership please complete all questions*
MonthDayYear
Membership ($20)*

NewRenewal
Renewal membership year runs from October 1 to September 31 (of the following year).
If new membership registration occurs after June 1st, the initial membership year will run to September 31 of the following year.
Yearly Dues:
PLEASE NOTE: Actual payment amount has been updated to reflect a processing fee of 3.7% and a 49 cent service charge (courtesy of PayPal).
Membership Dues
PLEASE NOTE: Actual payment amount has been updated to reflect a processing fee of 3.7% and a 49 cent service charge (courtesy of PayPal).
Name*

First NameLast Name
E-mail*

Confirmation Email
New members will receive an invitation email to join our Google E-mail Group (this is our primary source of communication!). Instructions for joining will be contained in the email.
reuse existing membership data

noyes
Birthday (month and day are required, year is N/A)

MonthDayYear
Cell Phone*

Area CodePhone Number
Home/Work Phone

Area CodePhone Number
Alias/Nickname
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
The following selected options infers your consent to be included in the clubs directory and members only section of the clubs website.*

NamePhoneEmail
How did you hear about us?
Favorite Buffett Song:
Favorite Buffett Lyric:
My One Particular Harbor is:
I like mine with...
What kinds of events would you like to volunteer for:

Summer CHIILL Music Charity EventMisericordia EventsAlzheimer's WalkTailgatingHouse Concerts (hosting)Adopt-A-Highway
Anything we forgot:
Completion of this application and payment of dues is your consent to membership in this organization. As member you agree to bylaws adopted by the membership of the Chicago Parrot Head Club as well as Parrot Heads In Paradise, Inc., and the use of the above information by the club for matters pertaining to its operation and events. Activities organized by the club are for enjoyment of the membership of the Chicago Parrot Head Club. Our officers or members are not liable for any injury, loss or damage of personal property. Each member is responsible for his or her own behavior as well as that of their children. Chicago Parrot Heads, its members and its officers will not be responsible for your actions during your association with the organization. This contribution is not deductible as a charitable contribution for Federal Income Tax purposes per PHIP bylaws. The terms Jimmy Buffett, Margaritaville, Parrot Head(s), Parrothead(s), Parrot Head Club, Parrothead Club and PHC are registered trademarks of Margaritaville Inc.
Signature (initials):*
Our Meetings are at 7:30 pm, every third Wednesday of the Month at:

Another Rounds

5141 Main St

Downers Grove, IL 60515
Enter the message as it's shown*
Membership Payment

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USDPayment = (Membership Dues * 3.7% + $0.49) Processing Fee
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If Payment is not completed, application will not be submitted

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On-line Membership Application

PLEASE NOTE: Actual payment amount has been updated to reflect a processing fee of 3.7% and a 49 cent service charge (courtesy of PayPal).