Ikebana International North & Central American Region
Chapter Name & # Membership Application/Renewal
Membership Year - July 1, (2---) to June 30, (2---)
(Please print clearly)
PLEASE CHECK APPROPRIATE BOXES AND PROVIDE ALL APPLICABLE INFORMATION
• NEW MEMBER | • RENEWAL | • PROSPECTIVE MEMBER | ||||||||||||||||
• Regular Member | • Regular Member | • PREVIOUS PROSPECTIVE MEMBER Applying for Regular Membership | ||||||||||||||||
• Associate Member | • Associate Member | |||||||||||||||||
• No Change to Personal Information | • Address Change | • Telephone Change | • Email Change | • Other | ||||||||||||||
Last Name | First Name | |||||||||||||||||
Prefer to be called | Birth Month: | Birth Day: | ||||||||||||||||
Mailing Address | ||||||||||||||||||
City/State/ZIP | ||||||||||||||||||
Telephone (provide preferred number to receive calls) | ||||||||||||||||||
Ikebana School(s) Attending: | ||||||||||||||||||
DUES | ||||||||||||||||||
REGULAR MEMBERSHIP DUES • $ (BEFORE JUNE 1) Chapter Dues & II HQ: Full Membership [July 1 – June 30] • $ (AFTER JUNE 1) Chapter Dues & II HQ: Full Membership [July 1 – June 30] Previous I.I. Member Chapter Name ________________________________ Member No.________________ | ||||||||||||||||||
ASSOCIATE MEMBERSHIP • $ Associate Membership [July 1 – June 30] Specify Primary I.I. Chapter ___________________________________ Member No._______________ PROSPECTIVE MEMBERSHIP - AVAILABLE ONE TIME ONLY • $ Prospective Membership • $ Student Membership • $ Other [One time Offer Only] | ||||||||||||||||||
IKEBANA TEACHERS ONLY
I am a certified teacher* of – list School(s): | ||
*Please be sure you have provided verification of your school rank/level to our Membership Chair. | ||
If you are certified in more than one school, list the school in which you primarily teach and check below. | ||
School: | • Currently Teaching • Currently demonstrating | |
RELEASE • I do • I do not give this Chapter permission to use any image of myself or my arrangements for purpose of publication in Chapter publicity, email tree and posted onto the Chapter web page and Facebook or used solely for the purposes of Chapter activities.
This Chapter is an equal opportunity organization and will not allow discrimination based upon age, ethnicity, ancestry, gender, national origin, disability, race, size, religion, sexual orientation, socioeconomic background, or any other status prohibited by applicable law.
WAIVER OF LIABILITY The Chapter does not have private insurance coverage for public liability, property damage claims or other legal actions that may arise as a resultof its activities. Members release the Chapter and its advisors, officers, board members, and club/organization from any and all claims, demands, actions, or causes of action. Members of the Chapter assume all personal liability for any and all civil action taken against them. All members acknowledge that by accepting membership and the by-laws, they are aware of this waiver of liability. • I have read and agree with this statement.
Signature XX
This form and payment should be received by June 1. After June 1, the Late Payment will apply |
Make check payable to: Or e-payments accepted: e-check, Zelle or PayPal (add payment directions) |
Mail Form and Check to: |
Email Form to: |