Annual Dues: $5.00 Students / $10.00 Adults
APPLICANT INFORMATION
Name:
Current address:
City:
State:
ZIP Code:
Phone:
Email:
MEMBERSHIP INFORMATION
Circle Applicable:
Student (Grade _____)
Parent Grandparent Faculty/Staff
Business/Community Member
Member Name:
Contract Phone/Email:
Circle Applicable:
Student (Grade _____)
Parent Grandparent Faculty/Staff
Business/Community Member
Member Name:
Contract Phone/Email:
Circle Applicable:
Student (Grade _____)
Parent Grandparent Faculty/Staff
Business/Community Member
Member Name:
Contract Phone/Email:
Circle Applicable:
Student (Grade _____)
Parent Grandparent Faculty/Staff
Business/Community Member
Member Name:
Contract Phone/Email:
DONATIONS
To avoid the need for numerous fundraisers thoughout the year, please consider a tax-deductible donation to help
financially support the work of Darnell-Cookman PTSA. Any donation is truly appreciated.
Suggested Donation Levels:
$5.00 Individual
$25.00 Contributor
$100.00 Patron
$350.00 Angel
$10.00 Sponsor
$50.00 Family
$250.00 Corporate
$500.00 Phoenix
INTERNAL PTSA SUMMARY
Payment: CASH CHECK#______
Receipt:
Invoiced/Completed/Notes:
Yes No
Total Member:
Total Spirit Wear:
Received By & Date:
Notes:
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