Membership

 
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             2010  STAR DANCERS ANNUAL MEMBERSHIP APPLICATION

                     Dues: $5.00 (Effective 1/1/10 through 12/31/10)

 

CARD #

TITLE

LAST NAME

FIRST NAME

1)

 

 

 

2)

 

STREET ADDRESS:

 

CITY,STATE,ZIP:

 

PHONE NO.

HOME

 

WORK:

 
E-MAIL

 

Please check whether this is membership is NEW    or a RENEWAL

If new membership, how did you hear about the Star Dancers Club?

Would you be interested in assisting us at our monthly dance functions, special events, dance classes or other activities?  Yes No

RELEASE OF LIABILITIES:  The Star Dancers Club and the Department of Parks and Recreation of the City and County of Honolulu and the State of Hawaii are permitting and allowing me to participate in ballroom dance activities and instructions at the City and County of Honolulu and the State of Hawaii facilities.  For and in consideration of the foregoing, I hereby assume the risk of any injuries and loss of properties that I may sustain while participating in the Star Dancers Club activities and do hereby release and forever discharge and promise not to hold liable the City and County of Honolulu Parks Board, State of Hawaii and The Star Dancers Club, their respective officers, employees and agents from any actions, suits, damages, claims or judgments that may result from any personal injury or loss of property  This release is binding on me and my heirs and personal representatives and is valid for all The Star Dancers Club activities that I participate in.

SIGNATURE_____________________________________________DATE__________

SIGNATURE_____________________________________________DATE_________

 

Please print and send form and check to:

The Star Dancers Club

c/o Wayne S. Haraga

2100 Date Street

#1406

.Honolulu, Hawaii 96826

 

 

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