The Holland - America Club of Dallas, Texas

Fill in the information as you would like it to appear in the Holland-America Club Directory.

Name
(First): (Last): Speaks Dutch? Yes No

Spouse's Name (Last Name is optional)
(First): (Last): Speaks Dutch? Yes No

Street Address:

City: State: Zip Code:

Phone:

Mobile:
***The mobile number will normally not be printed in the Holland-America Club directory, Tulip Talk or website. However, it will be published if it is the only phone number provided.

E-mail:
May we contact you regarding HAC related events, information via email? Yes No

Your Birthday: Month Day Spouse's Birthday: Month Day

Names of Children under 18 years of age:
Birthday: Month Day Year Boy Girl
Birthday: Month Day Year Boy Girl
Birthday: Month Day Year Boy Girl
Birthday: Month Day Year Boy Girl
Birthday: Month Day Year Boy Girl

May we have permission to print the above information in our directory and use
the birth dates for Happy Birthday wishes in the Newsletter? Yes No

I, by submitting this form, do hereby declare that when I, my spouse and child(ren) will be participating in various activities of the H.A.C. I assume all risks and hazards incidental thereto, but not limited to, transportation to and from said activities, and do hereby wave, release, absolve, indemnify and agree to hold harmless the H.A.C., its officers and members from any claim arising out of injury during any activity authorized by the H.A.C..

This agreement is effective from the date of submission and remains valid as long as you are a member of the Holland America Club of Dallas.

Any Comments or Notes for the Membership Chairperson:

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