Form for Member Confirmation, Records & Directory

Please take a few minutes to complete this form by August 5. Only one member of your household needs to complete the form.

By completing this form, we will know that you still consider yourself a member of IHC and provides an opportunity for you to make your 2020 Gift from the Heart contribution.

Filling out the form also allows us to make sure the information we have for you is current in our membership records and will be used for our new membership directory. We ask you to complete every applicable field. At the end, you may tell us what information you do not want published in the directory.

If we do not hear back from you, we will not include your name in the directory and will contact you to discuss your membership status.

Please check if this is applicable and forgo completing the rest of the form.
- I/We no longer wish to be a member of IHC
2020 Gift from the Heart Commitment Amount*

IHC relies on our members to make a meaningful contribution which enables us to offer all that we do. If you are unable to make a 2020 Gift from the Heart contribution, we will understand, as no one will be turned away due to financial hardship. If this is the case, please enter zero as your amount and contact our Executive Director, Dan Silien by August 5, to confirm that this is your situation so we can update our records to retain your membership.
Individual Adult or Family Name(s), Last, then first*

Please tell us how you want to be listed, for example: if you are a couple (of any variety): Goldberg, Morty and Esther or if you have different last names: Goldberg, Morty and Feinstein, Esther or if single: Cohen, Gladys. Any children in the household will be listed below. For consistency in the directory, we will decide the order of the first names, when the last names are the same.
Street Address (Main Address for Directory Listing)*
City*
State*
Zip Code*
Secondary Address

Please complete this section if you want mail to be sent to this address during certain months of the year (ie vacation home). If not, just skip.
City
State
Zip Code
Months to receive mail at this secondary address
Home phone number (If you still have a landline)
Secondary (Vacation) phone number

If you use your cell phone number there, please let us know.
Adult 1: Last Name*
Adult 1: First Name*
Adult 1: Birthdate*
MM slash DD slash YYYY

Don't worry, this is for internal use only, not the directory.
Adult 1: Mobile phone number*
Adult 1: Email address*
Adult 2: Last name
Adult 2: First name
Adult 2: Mobile phone number
Adult 2: Email address
Adult 2: Birthdate
MM slash DD slash YYYY

Don't worry, this is for internal use only, not the directory.
Wedding Anniversary Date (if applicable)
MM slash DD slash YYYY

Don't worry, this is for internal use only, not the directory.
Child #1 living at home: name, first and last
Child #2 living at home: name, first and last
Child #3 living at home: name, first and last
Child #4 living at home: name, first and last
Child #5 living at home: name, first and last
Child #6 living at home: name, first and last
List any of the fields you do not want published in the directory

Adult names will be printed, but if you do not want one or more of your address, home phone, mobile number(s), email address(es) and children's name(s) printed, please specify here. It is important that you complete ALL of the above applicable fields in this form so we can make sure your information is correct and complete in our membership records, even if you do not want the information included in our directory. Thank you for helping us with this important task.

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