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Last name First nameMaiden name
Married                                                      Spouse's name
Home PhoneCell Phone
Email address:

Would you give permission to share this information through:
Directory mailout ?                            yes  no
Emailed newsletter ?                          yes  no
Verbal communication?                      yes  no

Would you like to receive information about our class?        yes    no

Please include comments, suggestion, info on classmates, or anything else you'd like: