MEMBERSHIP APPLICATION  LHSAA

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                                                        $____________

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

 

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