Member Profile: **Please Print**

Student Name (Last, First): ____________________________________________________

**PLEASE PRINT**
Grade: ______________

Current Age: ____________

Years in Club: ________

Shirt Size: _______Students Email: ___________________________

Students Cell Phone: ___________________________

Birthday: ________________________

Texting allowed: Yes or

No

1. Have you taken Intro to IT? YES or NO

2. Have you completed MOS Bundle Certification? YES or NO
3. Are you enrolled in an upper level business class for 2016-2017? YES or NO
Co-curricular Membership Dues- If you answered yes to items #2 and #3, attach a copy of
your certification and your schedule or a statement from Guidance. Your dues is only $16.
Parent/Guardian Information:
Guardian(s): ________________________

Relation: ______________________

__________________________________
*NCSB Approved Volunteer: Yes or No
*Volunteers must be board approved. If you wish to volunteer with FBLA, please complete a
school board volunteer application form.
Home phone: _______________________

Cell phone: ____________________

Address: ___________________________

Work phone: ___________________

__________________________________

State: ________________________

City: ______________________________

Zip Code: _____________________

Parent/Guardian Email: ___________________________________________________

Additional Information:
Emergency Contact(s):

Phone Number(s)

_________________________________________

__________________________

_________________________________________

__________________________

*A NCSB Notarized Medical Authorization Form & Drug Testing Consent Form, and FBLA Dress Code Form
(attached) must be submitted with this form and cash or check (payable to HMSHS) for your FBLA DUES. This
covers local, district, state, and national dues..
Any known allergies: _____________________________________________________________
Visit the Florida FBLA-PBL website www.floridafbla-pbl.com and review the FL FBLA Dress Code and Code of
Conduct. I understand the policies and agree to comply when I participate in FBLA events. I agree to comply with
official dress code for FBLA in my local chapter as instructed by my adviser/chapter officers.

Signature _______________________________________________ Date _______________________

Membership Status (Officer Use Only): Dues Paid: ____________ Funds Raised: ____________

Meeting Attendance Totals: ____________ Hours Volunteered: ____________