PTA MEMBERSHIP FORM

Dues are $8 per person or $12 per family.	Please return to : Ceba Vestergaard
Make checks payable to: MHS PTA	115 Basswood Drive
	Middletown CT 06457

First Member Name:	__________________________________________________
Second Member Name:	__________________________________________________
(if paying Family Membership)

Children's Names:	_________________________	Grade:	_____
	_________________________		_____
	_________________________		_____

Address:	__________________________________________________
Home Telephone:	__________________________________________________
Email:	__________________________________________________
Note: Your phone & email will never be distributed and will only be used for PTA correspondence. Please indicate your interest by checking the following activities in which you'd like to volunteer.

Advocacy/MSA _____   Membership   _____ Arts Committee _____   MHS Website   _____ Reflections _____   Mini Grants   _____ Effective Behavioral Support _____   Hospitality   _____ Project Graduation _____   Quiet Kudos   _____ Senior Honors Reception _____   PTA/Vo-Ag Plant Sale   _____

Would you be willing to help during the school day? _____ Yes   _____ No

FOR PTA RECORDS

Amount Paid:

__________

Cash:

__________

Check #:

____________________

Date Paid:

____________________

Received by:

______________________________