THE WESTERN HIGH SCHOOL ALUMNI ASSOCIATION, Inc.

P.O. Box 203 – Vienna, VA 22183-0203

MEMBERSHIP FORM

Please provide names, not initials.  Please PRINT and fill out form COMPLETELY!

Graduate:  Class of ________                                                              Date:  ___________________

Non-graduates:       ________  (Indicate Class year preferred)

Name:  _______________________________________________________________________________________

                        LAST                              FIRST                             MIDDLE                                    MAIDEN NAME  (Alumnae only)

ADDRESS:  _________________________________________________________________________     _ _ _ _ _ + _ _ _ _

                                    STREET               APT. #              CITY                              STATE                            ZIP+4   

PHONE:     ___________________________                                        ________________________________________

                                         HOME                                                             Name as it appears in phone book                

OTHER PHONES:  ___________________________________________________________________________________

                                    WORK                          CELL                    FAX                           EMAIL

OCCUPATION:  ____________________________  COLLEGE/UNIV.  ___________________________

SPOUSE:  _______________________________________________________________________________________

                        LAST                              FIRST                             MI                                 MAIDEN

Did spouse attend Western ?   ______   Class:  ______________

CHILDREN:   ______________________________________________________________________________________

                        Please give full names, addresses, spouses, & phone numbers. Attach a sheet if needed.

                        This helps us locate you when mail is returned.

MEMBERSHIP CATEGORY

                                                            _____ Annual ($20)                     _____ Lifetime ($150)

Make checks payable to:                                   

WHSAA                                              _____ Friend   ($25)                          ____   Benefactor ($300 min.)

P.O. Box 203

Vienna, VA 22183-0203                  ______   Patron  ($50)                     ____    For Postage

_____  Sponsor ($100)                      ____   Other

The annual membership period is from January through December.  Dues and contributions are tax-deductible for

Federal income tax purposes to the full extent allowed by law.

IMPORTANT!

Please provide a full name & address of two persons with whom you keep in touch.

(1)  _______________________    ________________________    _________    _______________________    ___________________

                LAST                                       FIRST                                     MI                            SPOUSE                 RELATIONSHIP TO YOU

_________________________________________________________________________________________________________

STREET                                                  CITY                                        STATE                    ZIP                                          PHONE

(2) 

________________________   _____________________   ______              __________________       _____________________

                LAST                                       IRST                                        MI            SPOUSE                         RELATIONSHIP TO YOU 

_________________________________________________________________________________________________________

STREET                                                  CITY                                        STATE                    ZIP                                          PHONE