Name of Parents or Guardian___________________________________Phone Number_________
Address__________________________________________City_________________State___  Zip________ Neighborhood/area _________________________ E-mail________________________

Do you wish to have your e-mail address published in our directory?  yes____  no ____
Would you be willing to call families who do not have email or in the case of urgent alerts (rare) to pass along any important announcements?  yes____  no____

Children (Please include those who are not home schooled too)
Name ___________________    Age _____     Birthdate _______   Approx. Grade _____
         ___________________           _____                    _______                         _____
         ___________________           _____                    _______                         _____
         ___________________           _____                    _______                         _____
         ___________________           _____                    _______                         _____

Type of Curriculum Used (This information is used to help others when questions about curriculum arise. Your details, including grade level, help!) ______________________________________________________________________
       _____________________________________________________________________________________________
       _________________________________________________________________________________________________

Privilege Fee –  $10.00: Includes Heart & Home monthly newsletter and a copy of our directory for the current year. (July 1 – June 30): A portion of the Privilege Fee will help to cover incidental expenses of the support group. Check here if you do not have email and need a copy of the newsletter mailed to you each month. ____  Please note: The email version is sent as a MS Word attachment. If you do not have MS Word on your computer, you may have difficulty in opening it correctly. Please check here if you have email but DO NOT have MS Word available.  _______

PLEASE NOTE: You do not have to pay the "Privilege Fee" to participate in the meetings or activities of Heart and Home Educators. The "Privilege Fee" simply covers the costs of printing the directory, postal fees, and other incidental expenses of the group, which can include group-sponsored activities throughout the year.

___ Yes, I would like my family profiled in the newsletter this year (very general info to help us get acquainted w/ the families in our group.) Please list any info you would like shared (e.g. hobbies, interests, special talents)
     _______________________________________________________________________________________________________
___ No, I prefer to NOT have my family profiled in the newsletter.