Hanarry Swim and Racquet Club

Change of Information

Member Number ___________________________

Member’s last name ___________________________

Member Phone ___________________________

Member Contact Email ___________________________

Date of this request ___________________________

Are you relocating? If so, your new address is:

________________________________________________

________________________________________________

________________________________________________

New additions to the family? Please list them below:

Member (child/dependant) Name ___________________________

Member D/O/B ___________________________

Deletions to the family? Please list them below:

Member (child/dependant) Name ___________________________

Member D/O/B ___________________________

I am the rightful owner of the above numbered membership and do hereby request the membership chairman to modify the details as outlined above.

Signed,

________________________

Print and complete this form and mail it to HSRC, PO BOX 294, Lilburn, GA 30048

Form created 6/15/2001 (DJE) Modified 4/13/02 MAD