Membership Form

To join the Central Illinois Parrot Head Club, please fill out this online application and press the Submit button below. Membership dues are $20 for the first person and an additional $15 for each additional person at the same address. When renewing, a discount of $5 per person will be given if the renewal is received before membership lapses. (Only one newsletter is mailed per address.) You can pay your membership dues at the next club event, or by mailing a check to:

Central Illinois Parrot Head Club
P.O. Box 1063
Bloomington, IL 61702-1063

Please note, your membership will not start until your dues are received.

* Denotes a required field

*How many people is this membership for?
*Name:
*Address:
*City:
*State
*Zip code:
*Birth Date:
 mm/dd/yyyy
Home Phone:
 example 123-456-7890
Work Phone:
 extension
Email:
Hometown:
Occupation:
Nickname:
One word to describe myself:
Hobbies:
It really upsets me when:
Favorite vacation spot:
Favorite Buffett song:
Ultimate fantasy:
To me, luxury is defined as: