QUESTIONNAIRE FORM

QUESTIONNAIRE FORM

Name:_____________________________ Married Name:___________________

Spouse Name:__________

Address:____________________________________________________________

Email address:________________________________________

Your current occupation:_________________________________

Employer:_____________________________________________

Spouse occupation:_______________________________________

Spouse Employer:_______________________________________

Children: Name Age

_________________________ ____________

Advanced education obtained since High School (Include School, Degree/Certificate earned, etc.):_________________________________________________________________

Current Interests/Hobbies:________________________________________________

Current organizations/groups to which you belong:_______________________________

My favorite CHS memory:_________________________________________________

(Booklet - pick up at reunion - $5.00 - via U.S. Mail - $6.50)

Print out and return with or without the reservation form to: Janet Justin Potter, 1212 W. 15^th St., Davenport, Iowa 52804

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