NEW MEMBER APPLICATION

Please PRINT all information clearly.

Name: _______________________________________________________________________

Address: _____________________________________________________________________

City: ________________________________________________ Zip: ____________________

Age:_______________ Grade: _________________ T-Shirt Size: _______________

Demographics: Please check all that apply: (optional, for federal reporting purposes)

____ Male ____ Female ____ Hispanic ____Non-Hispanic

____ Caucasian ____African/American ____ American Indian

____ Asian (Filipino, Japanese, Korean, Asian Indian, Thai) ____ Asian (all others)

____ Native Hawaiian/Pacific Islander

____ Handicapped (Classified ADA)

Class Schedule:

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For teacher use:

___ Information entered in HOSA affiliation system _____Fees paid $__________ Cash/Check # _______