2018-19 CW HSA Membership Form
Please fill out the following to become a member of the Cook-Wissahickon HSA. Please note, your information will all be private and will not be shared with any third parties. After you submit you'll see instructions for paying via Paypal or by check or cash! Thanks so much - we're looking forward to a great year!
Parent/Guardian 1 First Name: *
Your answer
Parent/Guardian 1 Last Name:
Your answer
Street Address *
Your answer
Zip Code *
Your answer
Email *
Your answer
Phone Number
Your answer
Parent/Guardian 2 Name
Your answer
Street Address
Your answer
Zip Code
Your answer
Email
Your answer
Phone Number
Your answer
Student 1 First Name (If non-guardian member, please type N/A) *
Your answer
Student 1 Last (If non-guardian member, please type N/A)
Your answer
Student 1 Grade *
Student 1 Homeroom Teacher
Your answer
Student 2 First Name
Your answer
Student 2 Last Name
Your answer
Student 2 Grade
Student 2 Homeroom Teacher
Your answer
Student 3 First Name
Your answer
Student 3 Last Name
Your answer
Student 3 Grade
Student 3 Homeroom Teacher
Your answer
Do you wish to receive HSA news and announcements *
Are you interested in being contacted specifically for for any of the following volunteer needs?
Please see instructions for paying for your HSA membership via Paypal or cash or check after you submit your responses! Dues are $5 per family. Any additional donations are appreciated! Thanks! Questions about payment? Email cookwissahickontreasurer@gmail.com
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