Membership, Directory, Yearbook, and Remittance Form

May family information be published in the directory?  All info __ Only circled items  ___ None at all ___

Family Information**:  Please print clearly.   Please complete all information even if you do not want it published.

Parent/Guardian	Directory?		Directory?
Last Name:	Y or N	First Name(s):	Y or N
Address:	Y or N	Phone:	Y or N
Neighborhood:	Y or N	E-mail:	Y or N

All children’s names will be listed with their class in the directory.  Only one form needed per family!

Student’s Name (firstname lastname)

Grade

Teacher

PTA Membership: Membership is $5.00 per person    Life Member?

Parent/Guardian Full Name	Faculty? (yes or no)	PTA Amount
Would you like to make a donation to Friends of Kerr?  (Levels listed below) Name to list donation by in the directory? ___________________________________________
Levels: Gold $500 and up, Silver $100-$499, Bronze $26-$99, Friend up to $25                         PTA Subtotal

Yearbook Order Information:

	Number Ordered	Cost	Yearbook Total
Pre-order your yearbooks here!		22.00

Total Remittance:

PTA Subtotal

Yearbook Total

Total Remittance (make checks payable to “Kerr PTA”)

** Due to privacy laws, your family information will be included in the Student Directory ONLY if you indicate the information you wish to be published AND you sign in the space below.  Check the space at the top if we can publish ALL the family information listed. 

The family information I have indicated above may be included in the PTA directory.

Signed: __________________________________________________   Date: __________________________

PTA Use Only:  

Name filed under: ________________________      Amount ___________      Check No. _________     Date Received _________

Treasurer ___________     Membership____________      Directory ____________      Filed ________________