Name: ______________________________________________________
Please list all adults if a family membership
Address: ____________________________________________________
_______________________________ ZIP _________________
Home Phone: _________________________________________
Work Phone: _________________________________________
E-Mail Address: ________________________________________
# of Children: _________________________________________
Schools they attend: ___________________________________
Please contact me about involvement opportunities: _________ yes
_____ Single Membership $5 for a year or $10 for 2 years
_____ Family Membership $10 for a year or $20 for 2 years
_____ Student Membership $2 for a year or $4 for 2 years
_____ Corporate Membership $25 annual membership fee
Donations are always appreciated - $10____ $25____ $50____ Other _____
Please make checks payable to Springfield Parents for Public Schools
Print this form and mail to: Springfield Parents for Public Schools
P. O. Box 7452
Springfield, IL 62791
