Membership

RENEWAL _____ NEW MEMBER _____ FRIEND ______ CLASS OF _______

NAME ______________________________________________

SPOUSE ______________________LANGLEY GRAD? YES __ NO __ YEAR _____

ADDRESS _______________________________________________________

CITY, STATE, ZIP CODE ______________________________________________

PHONE ________________ CELL ________________ EMAIL_________________

____ NEW ($12 per year for individual or couple) $____________

____ RENEWAL ($12 per year for individual or couple) $____________

____ SCHOLARSHIP DONATION $____________

____ GENERAL FUND & OUTREACH DONATION $____________

____ROUND UP DOLLAR DONATION $____________

Please mail form and check to: LHSAA, BOX 4508, Pittsburgh, PA 15205

Langley Alumni