Membership Form 2008-2009

North West Arkansas Christian Home Educators Association

Your Name: __________________________________________________________________________________________

Address: _____________________________________________________________________________________________

City: _____________________________________________________ State: __________ Zip: _______________________

E-mail: _______________________________________________________________________________________________

Home Phone: _______________________________________ Cell Phone: ________________________________________

Your Employment Outside the Home (if applicable):

Employer: ______________________________________________________________________________________________

Occupation: _______________________________________________________ Work Phone: __________________________

Your Spouse's Info:

Name: __________________________________________________________________________________________________

Employer: _______________________________________________________________________________________________

Occupation: ______________________________________________________________________________________________

Your Children's Info: (Please list & notate college or public schooled children as well)

Name: _____________________________________Date of Birth: _______________ Grade (in Sept 08):__________________
Name: _____________________________________Date of Birth: _______________ Grade (in Sept 08):__________________
Name: _____________________________________Date of Birth: _______________ Grade (in Sept 08):__________________
Name: _____________________________________Date of Birth: _______________ Grade (in Sept 08):__________________
Name: _____________________________________Date of Birth: _______________ Grade (in Sept 08):__________________
Name: _____________________________________Date of Birth: _______________ Grade (in Sept 08):__________________
Name: _____________________________________Date of Birth: _______________ Grade (in Sept 08):__________________
Name: _____________________________________Date of Birth: _______________ Grade (in Sept 08):__________________
Name: _____________________________________Date of Birth: _______________ Grade (in Sept 08):__________________
Name: _____________________________________Date of Birth: _______________ Grade (in Sept 08):__________________

Church Name: _________________________________________________ City: _______________________________________

Curriculum Used: ___________________________________________________________________________________________

____________________________________________________________________________________________

Home Business Information:

Business Name: ______________________________________________________________________________________________

Address: ___________________________________________________________________________________________________

City: _____________________________________________________________ State: ___________ Zip: _____________________

E-Mail: _____________________________________________________________________________________________________

Phone: _____________________________________________________________________________________________________

Business Description: __________________________________________________________________________________________

____________________________________________________________________________________________________________

Membership Dues: $20.00 per family per year.

NWACHEA's Membership Year begins August 1st.

Membership Dues are not refundable and are not prorated.

Payment made by: □Check (# _______________) □Cash

Liability Release: I release NWACHEA, its governing board or committee members, and its volunteer workers from any and all claims arising from participation in activities scheduled by or associated with NWACHEA.

Signature: ___________________________________________________________________ Date: ________________________

Membership information is published in a private NWACHEA directory. If you do not wish to be listed, please state so in the following comment area.

Enter additional comments in the space below:

_____________________________________________________________________________________________________________

NWACHEA of Rogers, P.O. Box 1414, Rogers, AR 72757-1414
Contact: Zoie Fair, E-Mail: mnzfair@sbcglobal.net

You are invited to join the NWACHEA E-Mail Loop. For more info visit:

http://nwachea.topcities.com
Page Revised: Aug 9, 2008