Website: http://nwachea.topcities.com
email loop: homeschools@yahoogroups.com
Father's Name: ____________________________________________________________________________________________________________
Mother's Name: ___________________________________________________________________________________________________________
Address: _________________________________________________________________________________________________________________
City: ___________________________________________________________________State: ____________________ Zip: ____________________
Home Phone: ___________________________________________________ Cell Phone: _________________________________________________
Email: ___________________________________________________________________________________________________________________
Father's Employer: _________________________________________________________________________________________________________
Occupation: __________________________________________________________ Work Phone: _________________________________________
Mother's Employer: ________________________________________________________________________________________________________
Occupation: __________________________________________________________ Work Phone: _________________________________________
Children's Info: (Please list & notate college or public schooled children as well)
1. Name: __________________________________________________ Date of Birth: _______________________ Grade (in Sept 08): ____________
2. Name: __________________________________________________ Date of Birth: _______________________ Grade (in Sept 08): ____________
3. Name: __________________________________________________ Date of Birth: _______________________ Grade (in Sept 08): ____________
4. Name: __________________________________________________ Date of Birth: _______________________ Grade (in Sept 08): ____________
5. Name: __________________________________________________ Date of Birth: _______________________ Grade (in Sept 08): ____________
6. Name: __________________________________________________ Date of Birth: _______________________ Grade (in Sept 08): ____________
7. Name: __________________________________________________ Date of Birth: _______________________ Grade (in Sept 08): ____________
8. Name: __________________________________________________ Date of Birth: _______________________ Grade (in Sept 08): ____________
9. Name: __________________________________________________ Date of Birth: _______________________ Grade (in Sept 08): ____________
10. Name: _________________________________________________ Date of Birth: _______________________ Grade (in Sept 08): ____________
Church Name: _________________________________________________________ City: ________________________________________________
Curriculum Used: ___________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Home Business Information:
Business Name: _____________________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________________________
City: _______________________________________________________________________ State: ____________________ Zip: _________________
Email: _________________________________________________________________ Phone: _____________________________________________
Business Description: _________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Membership information is published in a private NWACHEA directory. If you do not wish to be listed, please state here: _________________________
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 # __________________ or Cash _____________________ (check payable to NWACHEA)
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: __________________________________
Mail membership form and payment to NWACHEA, PO Box 7596, Springdale, AR 72766
Contact: Donna Farris at bdfarris2@sbcglobal.net or Sheri Hampton at shampton10@cox.net