

Diane Singler, Promotions Chairperson
Print this form, detach, and mail it along with your annual dues to: Julia Crowe, Ex. Secretary, 841 Capps Ave., Nokomis, Il 62075.
Name________________________________________________________
Title__________________________________
School________________________________________________________
County_______________________________
School Address_____________________________________________________________________
Zip______________
Home Address______________________________________________________________________
Zip______________
School phone(______)________________ Home phone(______)________________
School fax(______)_______________
email address_____________________________________
Club Web Address___________________________________
_____Junior High/Middle School _____High School ____Number of active
students
_____Club membership $40.00 _____Individual membership $10.00
Signature___________________________________________________________
Date_________________________

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