This form may be mailed to CHEMPA at P.O. Box 2331, Mt. Pleasant, TX 75456.  In order to receive a monthly newsletter and annual membership directory, this form must be submitted with dues payment before the 3^rd Thursday in September.  The information submitted on this form will be included in a membership directory, as well as an internet “Yahoo Group” available only to CHEMPA members.  The Yahoo Loop is a private e-mail loop whereby members communicate opportunities, items of interest, and activity changes between newsletters.  When your membership form is processed, you will be receiving an e-mail invitation to join the Yahoo Loop; please respond quickly so as not to miss CHEMPA news.  If you are unfamiliar with how a Yahoo group/loop works and want to know more, please contact the Yahoo Moderator at chempatx@yahoo.com or contact an officer.

PLEASE PRINT CLEARLY 

Family’s last name: _________________________________________________________

Father’s name: ______________________Mother’s name: ________________________

Address:____________________________ Phone number: _________________________

City: _______________________________ State: _______________ Zip: _____________

E-mail address: _____________________________________________________________

Curriculum: ________________________________________________________________

Place of worship: ___________________________________________________________

Please list all children, including adult graduates and pre-school age children:

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“CHEMPA” MEMBERSHIP REGISTRATION FORM

(page 2 of 2)  

CHEMPA membership requires that families read, understand, and agree to abide by the “Mission Statement” and “Standards Of Behavior”.  Please check the boxes, sign and date below. 

__        I have read the “Mission Statement” of CHEMPA and agree to abide by it. 

__        I have read the “Standards Of Behavior” of CHEMPA and agree to abide by them. 

Parent Signature: _____________________________________ Date: __________  

DUES OPTIONS ~~ Please circle your preference below.

Checks should be made payable to CHEMPA. 

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