Poolesville High School PTSA 2015-2016 Membership Form

STUDENT(S) INFORMATION
Poolesville High School PTSA
2015-2016 Membership Form
First Name
Last Name
Grade Please complete for easy reference
PTSA membership entitles parents, guardians, community members, students, and staff a vote and a voice in PTSA-related activities.
We encourage you to join at the beginning of each school year and to attend meetings to make the most of your membership.
Membership Dues: Adults – $15.00/Students & Staff Members – $6.00
(Dues include your membership in the County, State and National PTAs and a copy of the PHS Student Directory to be distributed this Fall.)
Donations in addition to dues are tax-deductible and are greatly appreciated. Thank you!
Member - Last Name
Member - First Name
Address
(street, city, zip)
Membership Dues:
Adult (parent/guardian/community member)
Student/Staff Member
Phone Numbers
Email Address
$15.00 each # _____
$ _____
$ 6.00 each # _____
$ _____
Tax-Deductible Donation
$ _____
Total Amount Enclosed
$ _____
How many directories do you wish to receive?
Type of Membership
(adult, student, staff)
# _____
Please make checks for dues and donations payable to “Poolesville High School PTSA.”
Mail check and completed form to: PHS PTSA – Membership, 17501 West Willard Road, Poolesville, Maryland 20837