Heartland Spiritual Alliance – Membership Application 2015

HSA PO Box 300926, Kansas City, MO 64130 Please PRINT Legibly.

Membership dues are: $20.00 until January 31, 2015; $30 until February 28, 2015; $40 until March 31, 2014; $50 until April 30,

2015.

If paying by check or money order, please make out to HSA

To pay with Paypal: Pay July 1 or AFTER. Send the payment to treasurer@kchsa.org. You must put a comment in Paypal

that payment is for membership and indicate the member’s legal name as it appears on this form.

Legal Name: __________________________________________________

Preferred Name: _______________________________________________

Mailing Address: _______________________________________________

City: ___________________________ State: __________ Zip: __________

Phone Number: ____________________________ Home / Cell / Work (circle one)

Email Address: ________________________________________________

If you do not wish to be listed in a membership directory or online by-name notifications, initial here _________

Every HSA member is required to contribute a minimum of 20 hours of work to one or more of our committees

during the festival, or for setup & teardown immediately before or after festival. Please select which committees

you wish to work with. To make this choice more convenient for you, the committees are listed below.

Please PRINT your choices in order of preference in the places indicated. Please DO NOT check or circle the

committee names. Every attempt will be made to assign members to the committee(s) of their choice; however

members may be assigned to a committee based on the needs of the organization.

First Choice __________________________________________________________________

Second Choice _________________________________________________________________

Third Choice __________________________________________________________________

Community Fires*

First Aide*

Fundraising/Merchandising

Gaea Youth*

Hospitality*

Information Tech

Membership

Merchants*

Public Relations

Publications

Security*

Sacred Experience

Site/Sanitation*

Speakers & Bands*

Registration/Community Service*

Trash/Recycling*

Work Exchange*

Vehicular Management*

Vice President*

*primary function occurs at festival

I wish to be a member of the Heartland Spiritual Alliance. I am enclosing the annual membership dues and agree

to the by-laws and the governing policy of HSA. I also agree to actively participate in one or more of the above

Committees as one of the requirements of my membership, and to perform a minimum of 20 hours of active

service to HSA during the festival, or during set-up & tear-down of festival in the current membership year.

Signature_______________________________ Date __________________

For HSA Officer Use Only Annual membership dues in the amount of $________ received on ____/_____/_____ in the form of

_________________________. This membership is good from the date received and expires on June 30th 2015.