2010

BLACK DIAMOND PARROT HEAD CLUB

P.O. BOX #161

SUMMIT HILL, PA 18250

Membership / Renewal Form

Single $10.00 / Couple $20.00

Junior memberships (18yrs and younger) $5.00

annual memberships are renewable on January 1, 2010

Name: __________________________________________

Address: ________________________________________

City: _________________ State: ________ Zip: _________

Home Phone: ____________ Work Phone: _____________

E-Mail: __________________ Fax: ___________________

Birthday: ________________________________________

I am interested in the following activities:

Parties: ______ National Community Service: ______

Writing for Newsletter: ______ Concerts: ______

Producing Newsletter: ______ Weekend Trips: ______

Hosting Parties: ______ Deep Sea Fishing: ______

Local Community Service: ______ Camping: ______

Other: ______________________________________________________

How did you hear about the Club? ________________________

Comments / Helpful Hints: _______________________________

______________________________________________

The Obligatory Fine Print:

Each member of the Black Diamond Parrot Head Club is responsible for his or her own actions and behavior whether negative or positive. Membership in the club does not give the member permission to use Jimmy Buffett’s name, song titles, lyrics, names of businesses or other trademarked, copyrighted or reserved material owned by Jimmy Buffett; nor can any member use the logo of the Black Diamond Parrot Head Club, or Parrot Heads in Paradise Inc. Since Parrot Heads are known to enjoy a cold one, we support using a designated driver. This contribution is not deductible as a charitable contribution for federal income tax purposes.

SIGN: ______________________________ DATE: _____________

Renewal: Please circle One ( YES ) ( NO )