2008 MQHA Membership Form
please print this page out, and mail with payment (made payable to MassQHA) to:
Michelle Dionne 335 N East St., Amherst MA 01002

For more information on joining, e-mail Michelle at wolfview35@aol.com

______ Individual $25(one vote)

______ Life $200 (per adult person)

______ Youth $10 (must accompany an Individual or Mr/Mrs of a parent or Guardian

______ Mr & Mrs $35(two votes)

______ Associate $20 (no voting privileges)

______ Family $50 (voting privileges for each adult)

New Membership

Renew

Name : __________________________________________________

Address: _________________________________________________

City/State/Zip: ____________________________________________

Phone #: _________________________________________________

Youth Name & DOB: ________________________________________

Youth Name & DOB: ________________________________________

Do you wish to receive the MQHA Newsletter by email or regular mail? ____________________

E-mail address*: ____________________________________________

*Sign up to receive your online newsletter (over on the left of any MassQHA.com page)

Membership privileges begin upon receipt.

Don't forget...
You must attend 2 meetings from November to October to be eligible for Year-End Awards!