NHAHPERD Membership Form

Yearly Membership Rates Are:
Professional ($20), Student ($10), Retiree ($0)

Name:
Home Address:
Home Phone:
Home FAX:
Home eMail:
School / Business Name:
Work Address:
Work Phone:
Work FAX:
Work eMail:


Please check a response in each area:
Interest Area, Responsibility, Employment Level

INTEREST AREA

Health
PE
Recreation
Dance
Other
RESPONSIBILITY

Teacher
Student
Retiree
Administrator
Other
EMPLOYMENT LEVEL

Pre to Elementary
Middle
Secondary
College/University
Agency

Just Complete, Print and Send to:
Dianne Rappa, P.O. Box 123, Bath, NH 03740