Ebony Homeschoolers
Membership Registration Form
2008~2009

Name:     _________________________________________________________

Birthday:  Month: _________________________ / Day: ____________________

(spouse's name)   ________________________________________________________

Address: _________________________________________________________

City/State/Zip Code: ________________________________________________

Phone Number:  ___________________________________________________

Mobile Number: __________________________ Fax: _____________________

Email Address:  __________________________________________________
                                                        (please print clearly)

Please list all children.  Check those being homeschooled.

Name:                                                                         boy/girl      age/grade                  DOB

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

+++++++++++++++++++Do not write in this section.++++++++++++++++++++

_____invited/responded to loop              ______ added to roster                 ______ c'cards               ______ a-labels          _______TEV-bds   

MHEA  Y #______________   N                     _______ statement of understanding c / i           _______ renewed  2009-2010  

_______ phone database           ________ c-fone              _______ membership fee            _____     pending:________________________    

__________________________________________________________________________

How long have you homeschooled? ___________________

Gateway:  ____              HomeLife: ____                   FaithHeritage:  ____         

                      School system:_____            Other: ____________________________________

Church affiliation: ____________________________________________________________

Do you have any special skills, talents, hobbies, etc. you would be willing to share with the group?

__________________________________________________________________________

__________________________________________________________________________

Do you have any specific concerns that need to be addressed?  ______________________

________________________________________________________________________

Additional comments:     ______________________________________________________

__________________________________________________________________________

Signature:  _________________________________________  Date:   __________________

Statement of Understanding

I, ________________________________, understand that if I am to remain a member of Ebony Homeschoolers, I am to regularly attend the monthly meetings.  If I am absent 3 consecutive meetings, and fail to contact the leadership either by phone or e-mail, my membership will be made inactive.  I further understand that as a member of this group, it is my duty to be a help. 

I also understand that membership in Ebony Homeschoolers requires me to keep a current membership with MHEA.  I understand that I am to act in accordance with the requirements set forth by the state of Tennessee (or Mississippi) regarding homeschooling as well as the expectations of Ebony Homeschoolers as stated in the "Statement of Purpose" and "What We Expect."

Signature:  _________________________________________  Date:   __________________

2008-2009 MHEA Membership Application

All memberships/subscriptions expire on July 31 of each year regardless of the month in which they begin.  THEA annual dues are included in the prices listed.  We offer a discounted rate if you choose to view the newsletter on the internet (paperless).  Please select your membership:

$33 - Membership plus hard copy News & Views       $27 - Membership plus internet News & Views

MHEA Membership No. (if renewing) ________________ Widow(er) ___ (If yes, ask about additional MHEA services)
Last name - husband  _______________________  First name - husband  ________________________
Last name - wife ___________________________  First name - wife _____________________________
Address _________________________________  City _______________ State _____  Zip __________
County  ________________________  Support Group         EBONY HOMESCHOOLERS    
Home phone _______________   Work phone  ________________  Mobile phone __________________
Email ___________________________________  Email _______________________________________
Church attending _______________________________________________________________________
Child's first name, last name, grade ('08-'09), date of birth: ______________________________________
Child's first name, last name, grade ('08-'09), date of birth: ______________________________________
Child's first name, last name, grade ('08-'09), date of birth: ______________________________________
Child's first name, last name, grade ('08-'09), date of birth: ______________________________________
Child's first name, last name, grade ('08-'09), date of birth: ______________________________________
Child's first name, last name, grade ('08-'09), date of birth: ______________________________________
Child's first name, last name, grade ('08-'09), date of birth: ______________________________________
Child's first name, last name, grade ('08-'09), date of birth: ______________________________________
Please check box if you will NOT allow MHEA to use the names of your family members in our association's newsletters for the purpose of recognizing the individual's service to MHEA or for winning or placing in a competition sponsored by MHEA.

(Use back of form for additional children)