Republic of the Philippines

Department of Education
Region I
Division of Pangasinan II

OFFICIAL MEMBERSHIP FORM

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Club /Organization

NAME: ___________________________________________________ AGE: _____________

GRADE and SECTION: _______________________________________ GENDER: __________
ADDRESS: ____________________________________________________________________
MOBILE NUMBER: ____________________ EMAIL ADDRESS: _________________________
SECTION ADVISER: _____________________________________________________________
CLUB MEMBERSHIP:
Member Officer (Position: ______________)
DATE OF SUBMISSION: ________________________ MEMBERSHIP: Old New
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STUDENT’S APPROVAL

I fully understand the constitution and by- laws of this CLUB and fully commit myself to all relevant
activities scheduled and I am willing to adapt with the changes that this club may encounter. I will
respect the Club, the Club Adviser and the members.

________________________________________
Student’s Signature Over Printed Name

Noted:

_______________________________
Club Adviser
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PARENT’S APPROVAL

I fully understand the terms and conditions of this CLUB and allow my child to undergo training,
seminars and activities scheduled by the Club with due time information dissemination and waiver for
approval of attendance of my child.

_________________________________________
Parent’s Signature Over Printed Name

In case (s) of emergency, contact this person:

Name: ________________________ Relationship: ___________ Mobile Number: __________