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GPTA Membership Application

Annual Membership Application

_____Youth $5.00_____Adults $10.00_____Family $20.00

_____Renewal _____New member

Names, gender(circle) and birthdates of all members:

___________ __________________________ M F ____ / /______

____________ ________________________ M F _ _/ /______

____________ _________________________ M F __ _/ /______

_________ ____________________________ M F __ _/ /______

Address: _________________________________________

_________________________________________________

______________________________PA Zip__________

Phone: ____________________________E-mail: ___________________________

I HEREBY GIVE THE GPTA PERMISSION TO USE MY/MY CHILD’S NAME AND LIKENESS IN ANY AND ALL PROMOTIONAL OR ADVERTISING MATERIALS INCLUDING BUT NOT LIMITED TO NEWSLETTERS, BROCHURES, FLIERS OR WEBSITES.

____________________________ __________________________

Signature Date

Make checks payable and mail to: GPTA

Marie Del Vecchio, Membership Chairperson

12 Merion Lane

Collegeville, PA 19426

 

 
 
 
 
 
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