2025 PMHA REGISTRATION FORM
Due June 15
Name1
*
First Name
Last Name
Name2
First Name
Last Name
Address
*
Pinewood Street Address
Mailing address if different
City
State / Province
Postal / Zip Code
E-mail1
*
E-mail2
example@example.com
Phone (home)
-
Area Code
Phone Number
Phone (mobile1)
-
Area Code
Phone Number
Phone (mobile2)
-
Area Code
Phone Number
Publish email(s) and phone numbers in directory?
*
Yes to all phone/email (default)
Opt out of publishing emails
Opt out of publishing phone numbers
Opt out of publishing email AND phone
Other
Paperless (Digital directory only. NO means you want hardcopy.)
Yes
No
Do you want to register for the pool?
*
Yes
No
Pool membership household type
Senior (55+, 1-2 people) @$80
Family (3+ people) @$195
Couple (Under age 55, 2 adult) @$150
Single (Under age 55, 1 adult) @$100
Other
New member?
Yes (requires a one-time capital expense fee)
No
Capital Expense Fee
Senior (55+, 1-2 people) @$60
Other @$125
Need a replacement key?
Yes @$5
No
Click to complete POOL REGISTRATION information
Pool Only: Emergency Contact Name
First Name
Last Name
Pool Only: Emergency Contact phone (mobile preferred)
-
Area Code
Phone Number
Pool Only: Names of additional household members using the pool.
Pool Only: Sitter Name(s)
Signature
Click to toggle FEE SECTION
Annual Homeowner Dues (REQUIRED for pool members)
Dues @$15
Donation: Luminary
$5
$10
$15
$20
$25
Other
Donation: General (Pool, Events, Directory, etc)
$5
$10
$15
$20
$25
Other
Comments
Total owed $
Payment method
*
Mail/BillPay or drop off a check (to PMHA; c/o Nancy Pratt; 54 Forest Road, Essex Junction, VT 05452) - Ignore PayPal buttons/fields and message to enter an amount in My Products, then submit.
PayPal/Venmo (PMHA pays 3.49% + $.49/transaction) - any issues contact pinewoodmanor@gmail.com
My Products
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Registration Fee
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