MEMBERSHIP APPLICATION

Class Year

Name First Middle Last
Maiden Name

Address Address

City State Zip

Home Phone Work Phone

Fax E-Mail

Can we e-mail your newsletter Yes   No (I want hard copy)
Date of Birth Spouse's Name

Chillicothe Contact Person (Parent, Sibling, Relation, Neighbor) who will know your whereabouts for correct address confirmation.

Name Relation
Address Phone

Check any that apply from your years at Chillicothe High School - if you participated in any extracurricular activities not listed PLEASE add them.

Men's	Football	Basketball	Golf
	Tennis	Soccer	Track
	Cross Country	Wrestling	Baseball
Women's	Basketball	Tennis	Soccer
	Track	Volleyball	Cross Country
	Cheerleader	Homecoming Queen/Court	Softball
CO-ED	Choir	Band	Orchestra
	Natl' Honor Society	Revue	Drama
	Language Club	Other Club	Cavalites
TAX-DEDUCTIBLE MEMBERSHIP LEVEL
Individual - $15.00   Blue & White - $25.00   Cavalier - $50.00

Make check payable to and send to:
Chillicothe Alumni Association
421 Yoctangee Pkwy
Chillicothe, OH 45601
740-702-2287 ext 1160
e-mail: ccsdalumni@mail.gsn.k12.oh.us