MembershipYear_________(I have enclosed a check for $40.00)

 

Mr/Mrs_______________________________________________________(First and Family Name)

Adress___________________________________________________________________________

City_________________________________State_________________Zip_____________________

Tel#______________________Home__________________Office_________________Fax

__________________________E-mail

Birthdays: Please fill in names of family members and their dates of Birth
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Volunteer for                            Telephone tree       ( )                                    Party's                ( )
                                                Welcome Comm    ( )                                    Cultural Events   ( )
                                                Sports                    ( )                                    Kinderuurtje       ( )
                                                Boekenclub            ( )                                    Kaartavond        ( )
                                                KoffieKlatsch         ( ) In Your House

Disclaimer : I agree to hold harmless NETHERLANDS ASSOCIATION OF SOUTH FLORIDA and/or any persons who individually or as agents took part in any way in organizing and supervising the planned activities, for any injury or loss which may occur while I or any member of my family or my guest(s) are participating in these activities. I agree that I and those members of my family and guest(s) who are with me will participate in such activities at my (our) own risk.

Signature,  Date

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For office use only

check #                     ledenlijst:             verjaardaglijst:                 welkombrief:                 Krantje:

 

Please mail completed membership form with your check made payable to:

N.A.S.F. (Netherlands Association of South Florida)
Co-Treasurer,  Mariet van der Starre,  500 NW 1st Avenue Fort Lauderdale, FL 33301