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NAME
_______________________________________ BIRTH DATE
______________
ADDRESS
________________________________________________________________________
CITY
__________________________ STATE __________________ ZIP
______________
SPOUSE'S NAME
____________________________________ BIRTH DATE
_____________
DEPENDENT CHILD
_________________________________ BIRTH DATE
_________________
DEPENDENT CHILD
_________________________________ BIRTH DATE
_________________
DEPENDENT CHILD
_________________________________ BIRTH DATE
_________________
E-MAIL ADDRESS:
______________________________ FAX #:
_________________
PHONE NUMBER
(H)__________________________
(W)_________________________
BLOOD RELATIONSHIP TO
CLAN:
_________________________________________________
IMMIGRANT
ANCESTOR NAME (IF KNOWN):
_______________________________________
FROM WHERE ___________________ PORT OF EMBARKATION
__________________________
SHIP
__________________________ YEAR _______________ PORT OF
ENTRY ________________________________
SETTLED WHERE:
____________________________________________________________________________________
PARTICULAR
INTEREST OF EACH FAMILY MEMBER:
PIPING
________________________________________ HIGHLAND DANCING
_________________________________
ATHLETICS
____________________________________ GENEALOGY
_________________________________________
HISTORY
_____________________________________ COUNTRY DANCE
__________________________
LITERATURE
__________________________________ MILITARY HISTORY
________________________
SIGNATURE
_______________________________________________________ DATE
___________________________
PRINT & RETURN TO:
CLAN KENNEDY ASSOCIATION
New Member
____
% Clayton
Cannaday
Renewing Member
____
13605 SW Jenkins
Rd #65 .
Beaverton, OR 97005
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