Membership Application

 All information is for AHA use only and will not be sold, shared or released.

**  AHA membership includes entire household  **

New Member                                                                      Additional family members

Date: ____________                                                                             Name:__________________________Age:______

Name:  ___________________________________                        Name:__________________________Age:______

Address: __________________________________                        Name:__________________________Age:______

City______________________________________                       Name:__________________________Age:______

County:___________________________________                       Name:__________________________Age:______

State:   West Virginia              Zip: _____________                          Name:__________________________Age:______    

Phone: (304)_______________________________                                                                                                                   

E-Mail: ____________________________________                                                                                                               

***  Membership in CBA is not required, but encouraged  ***

1 Year AHA Regular Membership    $15.00

1 Year AHA + CBA Membership     $40.00

 AHA Lifetime Membership      $200.00

Make checks payable to:

AHA, P.O. Box 8184, South Charleston, WV 25303