"To stand still is to lose, To move is to gain, To change is to grow"  
--- Gene E. Megiveron
You need Java to see this applet.
Heartland Polish Rabbit Club
Counter
Online Membership Form
Individual Memberships $5 -
* Family Memberships $10 -
  • Family Members must all live at the same address
  • Youth turns adult on their 19th Birthday
  • Only 2 adults per family membership
* Required Fields
*
 Primary Name:
 dob
Member 2 Name:
 dob
Member 3 Name:
 dob
Member 4  Name:
 dob
Member 5 Name:
 dob
Member 6 Name:
 dob
Member 7 Name:
 dob
Member 8 Name:
 dob
*
 Mailing Address:
*
 City:
*
 State:
*
 Zip:
*
 Phone Number:
*
 Email Address:
Website Address:
Polish Varieties raised:
Your other Breeds:
Send payment to:

Bobby George
3654 N. State Rd. 827
Fremont IN 46737-9779
Review your
transaction, make
sure the amounts
are correct.

$10 a year for a
family membership,

$5 for a Individual
membership,

$8 for a patch,

$5 for a
newsletter/website
ad, Include any
extra amount for a
donation if that is
what you may
choose to do.