KEY CLUB MEMBERSHIP FORM - Cornell School District

K EY CLUB MEMBERSHIP FORM
NAME
Last Name First Name Middle Initial
ADDRESS
Street
Town State Zip code
PA
CONTACT INFORMATION
( ) -
Home Phone
( ) -
Cell/Mobile Phone
Return to Mr. Haskins. A
dues payment is not required
until October 15 th .
Email Address
DEMOGRAPHICS
Freshman Sophomore Junior Senior
Circle one
Homeroom Teacher
List any after-school or extra-curricular activities (i.e. band, softball, etc.):
Do you have an after-school job?
Why do you want to get involved with the Key Club?
- over-

DUES
Participation in the Key Club requires that members pay dues by October 15 th .
International Key Club Dues ……………………..…………….. $8.00
District Key Club Dues …………………………………………. $6.00
Total Dues ……………………………………………………....$14.00
SERVICE PROJECT INTERESTS
Check the boxes of activities you would most likely be interested in participating:
autism
children
environmental
elder care
food drive/food bank
fundraising
international (world-wide)
local (Pittsburgh area)
national (country-wide)
mentoring elementary students
mentoring peers
Relay for Life
Special Olympics
CLUB USE ONLY
Date Rec’vd:
Date Dues Rec’vd:
Faculty Sponsor Initial:
Faculty Sponsor Initial:
Receipt No.: