Miami Northwestern Senior High School



|CLUBS / ORGANIZATIONS Membership Application |

|Applicant Information |

|Name: |

|Date of |Home Phone |Cellular |

|birth: | | |

|Current address: |

|City: |ZIP Code: | Male Female |

|Ethnicity: African-American, (Non-Hispanic) Caucasian, Non-Hispanic Hispanic |

| |

|Asian/Pacific Islander Native American/Alaskan Native Multiracial/Multiethnic |

|ACADEMIC INFORMATION |

|Class Schedule |

|Period |Subject |Teacher |Room No. |

|1 | | | |

|2 | | | |

|3 | | | |

|4 | | | |

|5 | | | |

|6 | | | |

|7 | | | |

|8 | | | |

|Emergency Contact |

|Name of Parent/Guardian |

|Address: |Phone: |Cellular: |

|City: |State: |ZIP Code: |

|Relationship: |

|SPECIAL SKILLS/TALENTS |

| |

| |

|membership information |

|List the name of each club/organization |

|Club/Organization |Position held if any |

| | |

| | |

| | |

| | |

|Signatures |

|Signature of applicant: |Date: |

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