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FORT WHITE PARROT HEAD CLUB
983 NW HIGHLANDS LOOP
LAKE CITY, FL 32055
MEMBERSHIP APPLICATION
New Member
Renewal
What type of membership would you like to have:
(Keets 17 and under fly free)
Family $25
Single $15
If you are not paying online, please mail a copy of the application & your payment to the address at the top of the page.
Your contact information:
Name(s):

Address:

City:

State:

Zip:
Email address:


Birthdays His:

Hers:
Telephone number:

Cell Number:

Alternate Number:
Your interests:
I am interested in the following activities:
Parties
Writing for Newsletter
Producing Newsletter
Hosting Parties
Local Community Service
National Community Service
Club Promotions
Concerts
Weekend Trips
Outdoor Activities
Other
Fort White PHC is a non-profit organization for the people interested in Jimmy Buffet's music, books, and tropical spirit. Our goal is to assist in the environmental and community causes and to provide members with means of social interaction, while having a lot of Phun!!!
By agreeing on this membership form, I acknowledge that I am responsible for my behavior (and child's behavior, if applicable) and that I shall in no way hold Ft. White PHC liable for my actions or injuries at any event. I shall treat fellow members, guest, and hosts and their personal property, with respect. Members agree to abide by local, state and federal laws.
Agree
Disagree

1. Member Signature:___________________________________________________

2. Member Signature:___________________________________________________
Since Parrot Heads are known to enjoy a cold one, we support using a DESIGNATED DRIVER!

DISCLAIMER:   We are recognized by, but in no way attached to Jimmy Buffett or Margaritaville. We are not associated with the HK Management, MCA Records, Island Records or Margaritaville Records. The term "Parrot Head" is a registered trademark and shall not be used for the pursuit of profit; however, official PH Clubs are allowed to use the term "Parrot Head" for promotions.
How did you hear anout us
The Web
Radio
A Friend
Flyer
Other
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Single
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Family
Membership