VPE H&SL Membership Directory

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Parent/Guardian #1 Name *

Phone Number (Parent/Guardian #1) *

Address (Parent/Guardian #1) *

E-Mail Address (Parent/Guardian #1) *

Parent/Guardian #2 Name

Phone Number (Parent/Guardian #2)

Address (Parent/Guardian #2) - if different

Email Address (Parent/Guardian #2)

Child #1 Name *

Child #1 Teacher *

Child #2

Child #2 Teacher

Child #3 Name

Child #3 Teacher

Child #4 Name

Child #4 Teacher

Authorization to publish information in the VPE H&SL 2021-2022 Membership Directory. Check all that apply *

Parent/Guardian Name(s) - I authorize VPE H&SL to publish parent/guardian name(s) in the VPE H&SL 2021-2022 Membership Directory.

Parent/Guardian Phone Number(s) - I authorize VPE H&SL to publish parent/guardian phone number(s) in the VPE H&SL 2021-2022 Membership Directory

Parent/Guardian Email Address(es) - I authorize VPE H&SL to publish parent/guardian email address(es) in the VPE H&SL 2021-2022 Membership Directory

Home Address(es) - I authorize VPE H&SL to publish the home address(es) in the VPE H&SL 2021-2022 Membership Directory

I do not authorize for any information to be published in the 2021-2022 Membership Directory.

Required

Additional Information or Comments

Which level of membership did you purchase through http://www.vpe-hsl.org/membership.html *

$20 - Family Membership

$25 - Family Membership + $5 Donation

$30 - Family Membership + $10 Donation

$40 - Family Membership + $20 Donation

$50 - Family Membership + $30 Donation

$75 - Family Membership + $55 Donation

$100 - Family Membership + $80 Donation

Custom Donation

Name of individual completing this form *

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