Hui Heihei Wa'a
Membership Form

Instructions:
Fill out form, print, sign, and mail with your check to:

Hui Heihei Wa'a
P.O. Box 2852
Silverdale WA 98383

Last Name: First Name: Female
Male
Date of Birth: Age:
Address: City:
Swimmer?
Yes
No
Zip Code: E-mail Address:
Home Phone: Cell Phone:

Do we have your permission to publish your email address and phone numbers in the Club Directory? (note: this information will not appear on the club web site) Yes No

Membership Dues
 $85-Adult / $25-Junior(19 and under) / $125-Family of 4 +$10 each additional child
Additional Members
Name:   Age: Date of Birth: Swimmer?
Female
Male 		Yes
No
Female
Male 		Yes
No
Female
Male 		Yes
No
Referred by:
Waiver:
I/We, the undersigned, do hereby assume all risk and responsibility incident to any and all functions participated by Hui Heihei Wa'a and do hereby release Hui Heihei Wa'a from any liability for incident, damage, injury or loss as to my/or person(s) and/or my/our dependent children, (as applicable), or property, arising out of or incident thereto.


 
Signature
(parent/guardian for club member(s) under the age of 18 at time of registration)		   Date

 
Printed Name of parent/guardian for club member under age of 18   Home/Cell Phone