NORTH SIDE HIGH SCHOOL ALUMNI ASSOCIATION, INC



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Membership Application

______ New Member _____ Renewal Date______________

_____ $15.00 Member _____ $25.00 Sustainer _____ $50.00 Benefactor _____ $100.00 Patron

_____ $1,000.00 Life Membership (Can be paid at $250.00/year for 4 yrs)

( _____ In addition to my membership dues, I wish to contribute an additional amount to the

Scholarship Fund $___________.

( _____ In addition to my membership dues, I wish to contribute an additional amount to the

Grants Program $___________.

PLEASE FILL IN COMPLETELY EVEN IF NO CHANGES – Thank you!

Name (First) _________________ (Last)___________________(Maiden)____________________ ( Grad Year:_____

Married ____ Widowed_____ Divorced _____ Single ______ ( Date of Birth (mm/dd/yyyy) ____/_____/_____

Spouse’s Name _____________________________ Is spouse North Side graduate? Y / N (circle one)

Spouse’s grad year: ________ Spouse’s Maiden/School Name: __________________________________________

PRIMARY ADDRESS: HAVE SEASONAL ADDRESS? Y / N (please circle one)

Street ____________________________________ Street__________________________________________

City _____________________________________ City ___________________________________________

ST_________________ Zip__________________ ST__________________ Zip_______________________

Phone (______)____________________________ Phone (______) __________________________________

Cell PH# (______)_________________________ Months you will be at seasonal address:

Work PH# (______)________________ Retired? ____ _________ thru _________

E-mail ___________________________________ * needed to receive mail. Our mail cannot be forwarded.

Newsletter Preference: (check one) Mailed Paper Edition_________ Emailed Edition ______________

Please list any noteworthy news for the Totem Tales newsletter: (You may use second sheet if you need additional space.)

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Credit Cards Accepted: Name on Card ____________________________ Card Number _____________________________

Expiration Date:___________ 3 Digit Code: _____________ Zip Code:

Make checks payable to: North Side High School Alumni Association, Inc.

Mail to: NSHS Alumni Association, 475 East State Blvd., Fort Wayne, In. 46805

Web site and Online Directory:

E-Mail: info@ Telephone: 260-471-4499

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