J.W. York Elementary Parent Teacher Association (PTA)

MEMBERSHIP INFORMATION

**Please Join the PTA Today for 2010-11**

Contact Information:

Member Name(s)
Adult1: _______________________________________________________________________________
Adult2: _______________________________________________________________________________
Email: _______________________________________________________________________________
Zip Code: (for National PTA membership tracking) ___________________
Phone: __________________________

Student ___________________________________ Grade_______ Teacher___________________________
Student ___________________________________ Grade_______ Teacher___________________________
Student ___________________________________ Grade_______ Teacher___________________________

Itemization

Membership Amt: $________
(Not tax deductible)

Donation Amt: $_________
(Tax deductible)

Total Enclosed: $_________

Thank you for your generosity!

Membership Profile:
       Individual ($ 5.75) 1 adult membership
       Family ($ 10.00) 2 adult memberships

Donation Profile:
       Bronze Level ($25)
       Silver Level ($50)
       Gold Level ($75 or more)

Employer Matching Gift Program? Yes  No 
If yes, matching gift forms are available from your HR Department or by contacting the PTA.
It could double your contribution!
Company Name: ___________________________________________________________

Help with Passive Fundraising: FREE EASY MONEY FOR THE SCHOOL!

Harris Teeter VIC Card #: ____________________________________ (You can link up to 5 different schools)

Food Lion MVP Card #: ______________________________________ (Include small # before and after main #)

Kroger Plus Card #: __________________________________________