Emerald Coast Parrot Head Club Membership Form Welcome! Please complete one membership form per person. If you have any questions, please contact us at email@example.com. Please Select One:(Required) Renewal New Member Name(Required) First Last Nickname for Badge(Required) PHun Name (or First & Last Name) Example: "Mermaid Marcia" or "Pirate Pete". Birthday Month(Required)JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberBirthday Day(Required)Please enter a number from 1 to 31.Email(Required) Enter Email Confirm Email Phone(Required)Mailing Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Did You Hear About Us? (Please Select All That Apply)(Required) Friend/Family Club Member At Club Event Facebook Internet Search PHIP/Parrot Heads in Paradise Banner/Signage at Venue Other Referred By: Opportunities to Volunteer Membership Website/Social Media Nominations/Elections Merchandise Community Events Communications/Public Relations Executive Board Please select all that apply.Agreement(Required) Agree I certify that I have read the Club by-laws (https://ecparrotheads.org/join-us/), and I agree to the terms. I agree that any misbehavior that is contrary to Club rules may result in my expulsion from the Club. I agree to appear in club event photographs and videos. I understand that club membership dues are not deductible as a charitable contribution for federal income tax purposes. Membership Dues(Required) Price: Payment(Required) Credit/Debit Card - Pay Online Today (includes $2 tech fee) Cash/Check - Bring to Event or Mail to Us Other - Paid Via Square at Event Cash/Check Payment: Bring $25 to Membership Table at Next Event Or Mail $25 Check Payable to ECPHC To: ECPHC, PO Box 5052, Destin, FL 32540-5052 (include your full name in the check's memo line). If you have questions, contact us at firstname.lastname@example.org. Credit Card(Required) Cardholder Name Card Details CommentsThis field is for validation purposes and should be left unchanged.