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 Name) Example: "Mermaid Marcia" or "Pirate Pete". 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 Birthday Month(Required)JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberBirthday Day(Required)12345678910111213141516171819202122232425262728293031How 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(Required) Membership Website/Social Media Nominations/Elections Merchandise Community Events Communications/Public Relations Executive Board Not Interested Please select all that you are interested in.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. Payment Type(Required) Credit/Debit Card - Pay Online Today (Includes $2 Tech Fee) Cash/Check (Office Use Only) *Bring $25 Cash/Check 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 with your check). ***If you have questions, contact us at firstname.lastname@example.org. Membership Dues(Required) Price: Membership Dues(Required) Price: Total Credit Card(Required) Cardholder Name Card Details CommentsThis field is for validation purposes and should be left unchanged.