Membership Application 2024

First Name

Last Name

Birthday (month/date)

Additional Family Member(s)

Address

City

State

ZIP

Phone

Email address*

Name as you would like it on your badge (i.e. nickname)

Additional Family Members

I'm internet enabled

YesNo

I am interested in helping on a committee

YesNo

If you're interested in helping the committee, please let us know how you can contribute below.

Special EventsMembershipNewsletterPlanningRaffles

Do you have any other resources that would be of help to the club?

Dues

Individual: $25.00 ($30.00 if you need newsletter, etc. mailed)
Additional Family Member(s): $ 5.00 (for each member at same mailing address)
(This contribution is not deductible as a charitable contribution for the Federal income tax purposes.)

Member = _x $5.00 $ _ 25.00
Family = _x $5.00 $ __
TOTAL __

Please make your check payable to Desert Sharks PHC and send check to:

Donald Miller

Membership Chair

8316 N Solitude Way

Tucson, AZ 85743