Serteens Club of Hawaii Membership Form

MEMBERSHIP APPLICATION FORM
Legal Name *
Date of Birth*

MonthDayYear
Date
Preferred Name/Nickname*
School*
Graduation Year*
Shirt Size*
HOME ADDRESS
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MAILING ADDRESS

Only complete if different than home address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CONTACT INFORMATION
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
E-MAIL ADDRESS*
example@example.com
PREFERRED METHOD OF CONTACT

CELLHOMEEMAILTEXTOTHER (SPECIFY)
PARENT/GUARDIAN EMERGENCY CONTACTS
PARENT/GUARDIAN NAME 1*
RELATIONSHIP*
EMAIL ADDRESS*
example@example.com
PHONE NUMBER*
BEST TIME TO CALL
PARENT/GUARDIAN NAME 2
RELATIONSHIP
EMAIL ADDRESS
example@example.com
PHONE NUMBER
BEST TIME TO CALL
PARENT/GUARDIAN APPROVAL
STUDENT APPLYING FOR SERTEEN MEMBERSHIP
has my permission to participate in approved SERTEENS CLUB activities.

In consideration for the membership benefits my child receives from the SERTEENS CLUB, I hereby release and hold harmless advisors, directors, officers, members and the sponsoring HONOLULU SERTOMA CLUB from any and all civil liability for damages or injuries or claims of any nature arising from my child's participation in sponsored and/or approved SERTEENS CLUB activities. The sponsoring HONOLULU SERTOMA CLUB, its advisors, directors, officers and members are not liable for the actions of my child during participation in activities involving members of the SERTEENS CLUB. (See H.R.S. §662D-2)

I hereby authorize the advisor(s), director(s) and the sponsoring SERTOMA CLUB to use, reproduce, and/or publish photographs and/or video that may pertain to my child during participation in activities involving the SERTEENS CLUB and other media provided to the club. This authorization includes their image, likeness and/or voice without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSAs) or for other related endeavors.

This material may also appear on the SERTEENS CLUB or SERTOMA CLUB Internet Web Pages. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. The club may publish materials, use my child's name, photograph, and/or make reference to my child in a manner that the club deems appropriate in order to promote/publicize service opportunities.
PARENT/GUARDIAN SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Your application will be reviewed and an interview conducted. Upon acceptance, a $20 initiation fee will be due. Annual renewals will be $5.
If you would like to include any of your application documents (Copy of Test Scores, Short Answer, Recommendation Letter or Form) please do so below. Links to submit those documents later will be shared on the confirmation screen after submitting this form.

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MEMBERSHIP APPLICATION FORM

HOME ADDRESS

MAILING ADDRESS

CONTACT INFORMATION

PARENT/GUARDIAN EMERGENCY CONTACTS

PARENT/GUARDIAN APPROVAL