You may fill out the application below, or click HERE to print a copy.


Application for Enjoyment

(Items marked with a "*" are required)

This club is founded as a non-profit social club involved in the support of local charities - www.desmoinesparrotheads.com

APPLICANT 1

Name: *
Address: *
City *
State * Zip: *
Phone Number: * - -
Birthdate: * / / ex: 12 / 25 / 1946
Email Address: *

If this is a joint membership, please provide information on the other member or members.
To qualify, you must be married or living together within the same household.
Or, the additional member/members must be your children living within the same household.

APPLICANT 2


Name:
Phone Number: - -
Birthdate: / / ex: 12 / 25 / 1946
Email Address:
Relationship to Applicant 1:

Additional Applicant(s)


Name:
Birthdate: / / ex: 12 / 25 / 1946
Email Address:
Name:
Birthdate: / / ex: 12 / 25 / 1946
Email Address:
Relationship to Applicant 1:

Now for the PHUN stuff...

Please circle or fill in your response.
1. Do you like to have phun?
* Yes No
If you answered NO to question number 1, do not proceed with application.
2. What is your favorite alcoholic beverage?
*
3. What is your favorite non-alcoholic beverage?
*
4. Have you ever been to a Jimmy Buffett concert?
* Yes No
5. If Yes, how many?
*
6. What is your favorite Jimmy Buffett song?
*
7. How did you find out about the Des Moines Parrothead Club?
*
8. How did you discover Jimmy Buffett?
*
9. Describe any talents, qualities, or hobbies you have that you feel may be an asset to the club.
*


Please sign this application
(You must enter your name and select yes from the box on the right in order to continue)
Applicant 1 * * I agree to the disclaimer below Yes No
Applicant 2 I agree to the disclaimer below Yes No


By my signature above, I understand that the Des Moines PHC and PHIP, Inc. are recognized by but in no way attached to Jimmy Buffett and his business interests in Key West, New Orleans, Charleston, and Orlando. They are not associated with HK Management, MCA Records, Island Records, or Margaritaville Records. By my signature I recognize and comply that Mr. Buffett's name, his song titles, lyrics, names of businesses owned by Mr. Buffett, and the term "Parrot Head" are all registered trademarks and should not be used for the pursuit of profit. Clubs are allowed to use the term "Parrot Head" on t-shirts, etc., but NOT Jimmy Buffett's name. By filling out and signing this application, I accept that the Des Moines Parrot Head Club, itís officers, or any of the members are not responsible for my behavior. I accept that as an adult, I am responsible for myself, and not the actions of others.

Annual dues are $20 per person

Please mail your check(With name of applicant 1 and the date of website signup on the subject line) to:

Des Moines Parrothead Club
c/o Scott Peterson
Mailing Address:
2800 Giles St
West Des Moines, Iowa 50265




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