Personal Information

Please print in blue or black ink.

Full Name:

                        Last

First

M.I.

Address:

                        Street Address

Apartment/Unit #

                        City

State

ZIP Code

Home Phone:

(         )

Cell Phone:

(         )

E-mail Address:

Membership Information

$10.00 Dues

Yes    FORMCHECKBOX       No   FORMCHECKBOX

15 service hours

Yes   FORMCHECKBOX        No   FORMCHECKBOX

3.70 GPA 

Yes  FORMCHECKBOX          No  FORMCHECKBOX

I understand that as a condition of my membership I must maintain a 3.7 GPA (not rounded) must attend the induction ceremony, April meeting of my junior year, attend all 4 meetings and pay $10.00 dues my senior year.

Student Signature :

Parent Signature: