Individual Membership Application

Heart of America Singles Square Dance Association

INDIVIDUAL APPLICATION


Use this form by printing it and filling it out, OR
by downloading the source file, editing to fill it out, and printing.


Print Name__________________________________________________________________

Address_____________________________________________________________________

City________________________________________State________Zip_________________

Phone______________________________________Birth Date_______________________

Home Club__________________________________Town___________________________

Individual Membership $4.00 (2 yrs. $8.00, etc.) ����������� ����������� _______________
HASSDA Badge (with City/State bar) $6.50 _______________
Fun Badge (1" � 1" HASSDA logo) $1.00 _______________
Total amount enclosed (payable to HASSDA) _______________


I want my listing in HASSDA Directory to include my:

Name: Yes / No���������� Address: Yes / No����������Phone: Yes / No


I would consider helping on the HASSDA board:

Officer���������� Area Coordinator����������Special Projects


Make check payable to: ���������� HASSDA
Mail application & check to: ���������� HASSDA
PO Box 214
Mission, KS 66201


Members will receive a roster and a quarterly newsletter that will include details about singles activities and square dance festivals.


back to HASSDA home page ����� to club application


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