IMMACULATA ALUMNI ASSOCIATION

                            

APPLICATION FOR MEMBERSHIP & INFORMATION CHANGE FORM

Your membership dues are used to help fund scholarships for students entering Immaculata as freshmen,
as well as financial support for association activities

 

Right-click on form to print, then mail form and your check to: 
        Admin Office, ATTN Alumni Association, 320 N. Broadway, Leavenworth, KS 66048

 

            5  Enroll Me as a New Regular Member                  5  Address or Information change ONLY

            5  Enroll Me as a Friend of the Alumni                   5  Dues payment & Information Update

Please print or type                                                                                            Dues $20.00 per year

 

_________________________________________________|______________|________________________

Last Name/Maiden                      First Name         Middle         Class of               Name of Spouse

 

______________________________________________________________|__________________________

Street Address                                                   Apt. #                                 Phone Number

 

_________________________________________________________________________________________

City                                           State                 Zip + 4                               

 

 

Signature:  _______________________________  Date:  _________________        

 

E-Mail:  ___________________________ Permission to post my email on the Web page:   5  Yes     5  No