MEMBERSHIP APPLICATION
PO Box 909, Hot Springs, AR 71902 hsnprotaryclub@gmail.com
Personal Information:
Full Name
*
Dr.
Mr.
Miss
Mrs.
Ms.
Prefix
First Name
Middle Name
Last Name
Suffix
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Gender
*
Please Select
Male
Female
Marital Status
*
Single
Married
Other
Spouse/Significant Other Name
Dr.
Mr.
Mrs.
Ms.
Prefix
First Name
Middle Name
Last Name
Suffix
Spouse/Significant Other Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Anniversary
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Do you have a child(ren)?
*
Please Select
Yes
No
Child(ren) Information
Rows
Child(ren) Name
Gender
Birthdate
1
2
3
4
5
Home Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Home Phone Number
Format: (000) 000-0000.
Mobile Phone Number
*
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Personal E-mail
*
example@example.com
Work E-mail
example@example.com
Preferred Email to use for communications
*
Personal
Work
Name of HSNP Rotary Member Sponsoring You
*
Why are you interested in joining our Rotary Club?
*
What organizations are you currently involved in and in what ways do you serve (ie. Volunteer roles, community organizations, family activities, leadership positions held, etc.)?
*
Personal Hobbies & Interests
*
Have you ever been convicted of a felony?
*
Please Select
Yes
No
Provide Date(s) and Details Regarding Felony Conviction:
Business Information:
Company Name
*
Occupation/Job Title
*
Work Address
Street Address
Street Address Line 2
City
State
Zip Code
Company Website
Are you a past member of a Rotary Club?
*
No
Yes
Name of Club, Location, and Rotary ID Number
Rotary Club Achievements (ie.: offices held & date of service)
Other Information for Membership Consideration
Membership Acknowledgments
I understand that the membership initiation fee is due within 30 days of my acceptance into the Hot Springs National Park Rotary Club.
*
I have read and understand the above statement.
I understand that my membership dues must remain current. Dues may be paid monthly or annually in advance.
*
I have read and understand the above statement.
I understand that failure to keep my membership dues current may result in termination of my membership by the Hot Springs National Park Rotary Club Board. I further understand that if my membership is terminated while I have an outstanding balance and am not in good standing, I may be ineligible for membership in any Rotary club in the future, in accordance with Rotary International policies.
*
I have read and understand the above statement.
I hereby affirm that all information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that any false, misleading, or omitted information may result in the denial of my application or the termination of my membership.
*
I have read and understand the above statement.
I further acknowledge that applicants may be subject to background checks in accordance with Rotary International and Hot Springs National Park Rotary Club policies, particularly for participation in activities involving youth or vulnerable populations. I consent to such background checks if required.
*
I have read and understand the above statement.
By signing below, I certify that I have read and understand this application and acknowledge the financial obligations, commitments, responsibilities, and expectations of membership in the Hot Springs National Park Rotary Club. I agree to abide by the Constitution and Bylaws of Rotary International and the policies and procedures of the Hot Springs National Park Rotary Club.
*
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