Please Note: This information will be used in the 2009-2010 Member Directory

Mom’s Name______________________________ Dad’s Name ________________________________

                                        (first, last)                                                            (first, last)

Street Address_____________________________________Town________________ Zip __________

Phone_________________ E-mail ______________________________________________________

Please list all children living at home, even those who are not of preschool age.

        Child’s Name                       Birth Date                                        Pre School (if applicable)               

____________________                         _______________                      ____________________________

____________________                         _______________                      ____________________________

____________________                         _______________                      ____________________________

____________________                         _______________                      ____________________________

____________________                         _______________                      ____________________________

New Member? Yes___ No___

If you moved to the area recently, would you like a “Welcome Packet?” Yes___ No ___

Would you prefer to receive your monthly newsletter via email? Please choose one: Yes ___ No ___

Check here if you want to be contacted for volunteer opportunities within our organization _____

Are you a working parent? Yes_______ No_______

Please send your $40 annual membership dues (check made payable to BHPA) along with this completed form to

BHPA c/o Sabrina Christiansen

20 Suzanne Lane

Pleasantville, NY 10570

(There will be a $30 fee charged for all returned checks.)

The Byram Hills Preschool Association (BHPA) disclaims liability for any injury or damage incurred by a participant (or spectator) in any BHPA activities, including but not limited to, the annual fall carnival, the holiday parties, the monthly arts and crafts projects and the playgroups.  BHPA members and their invitees assume the risks associated with their presence at all BHPA events.  The BHPA reserves the right to photograph or record members for future promotional use. The undersigned hereby authorizes the BHPA to use photos taken of me and/or my child/children in any printed or electronic materials issued by or on behalf of the BHPA, including but not limited to the monthly newsletter, flyers, bulletins, press releases, email communications and the BHPA website. I also acknowledge that photos may be taken of me and/or my child/children at BHPA events by members of the media and utilized publicly by the media with or without the consent or input of me or the BHPA.

_______________________________________                  __________________________________________

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