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Select Membership Type
Membership Type:*
Primary Member Information
First Name:*
Last Name:*
Badge Nickname (if different):
Club Shirt or Tank Top
Zip Code:*
Significant Other Information (Family Memberships Only)
Significant Other (living in same household)
SO First Name:
SO Last Name:
Badge Nickname (if different):
Club Shirt or Tank Top
SO E-Mail:
SO Birthday:mm/dd/yyyy
Keet Information (Family Memberships Only)
Must be under 18 years of age and a dependent. Otherwise please add as a separate single membership.
Keet 1 Name:
Badge Nickname (if different):
Club Shirt or Tank Top
Keet 1 Birthday:mm/dd/yyyy

Keet 2 Name:
Badge Nickname (if different):
Club Shirt or Tank Top
Keet 2 Birthday:mm/dd/yyyy

Keet 3 Name:
Badge Nickname (if different):
Choose One...
Keet 3 Birthday:mm/dd/yyyy

Keet 4 Name:
Badge Nickname (if different):
Club Shirt or Tank Top
Keet 4 Birthday:mm/dd/yyyy
Additional Information
Tell Us More About Yourself*
How Did You Find Us?*
Information about Additional Club Volunteer Shirts
Each member receives one FREE Club Volunteer shirt (green with black lettering) or tank top (white with dark green lettering). Additional club volunteer shirts or tank tops may be purchased later. If you would like to purchase our special tie-dye club shirts, please email Chuck Esser at cje4879@gmail.com to inquire about availability and pricing.
Agreement and Release of Liability
(1) In consideration of being allowed to become a member of the Parrot Heads of Central Florida (“PHCF”) and to attend, work at, and/or participate in any and all activities, events, functions, and/or other occasions that PHCF has planned, sponsored, chaired, and/or otherwise supported, both before and at any time after I have become a member, I do hereby waive, release and forever discharge PHCF and its officers, agents, employees, representatives, executors, members, and all others, from any and all responsibilities or liabilities from injuries or damages arising out of, or connected with, my/my family’s membership in PHCF, my/my family’s participation in all activities, my/my family’s use of any equipment owned or utilized by PHCF, or any act or omission, including negligence by any representative or other member of PHCF.

(2) If I am joining PHCF with my spouse, my children, and/or any other family members or significant others, I understand that this Agreement and Release of Liability fully applies to each and every person who is joining PHCF under my membership. If, at a later date, any person or persons join PHCF under my membership, I understand that I will be required to sign and initial a new Agreement and Release of Liability.

I confirm that I have read and fully understand both paragraphs (1) and (2) above. I further confirm that if I did not fully understand both paragraphs (1) and (2), I requested and I received satisfactory clarification from one of PHCF’s officers, before submitting this form electronically.
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