Print Out This Form and Mail In With Your Payment By June 1

CHS 75 Class Reunion

  Name

  Spouse Name

  Address

   City, State ZIP

  Phone (home)

  Phone (work)

  Your eMail address

Booklet (Pick up at reunion)                            _______ x  $5.00    =    $_________

Booklet (via U.S. Mail)                                    _______ x $6.50     =    $_________

Golf Outing   (Pay at course - Emeis, Friday beginning at 11:00.  Thom May coordinating)      

    Myself    My Spouse/Significant Other                $27.00  each

Phil & Larry's   $8.00 each

    Myself    My Spouse/Significant Other              _______   x  $8.00  =  $_________            

Saturday Night Dinner   $28.00 each

    Myself    My Spouse/Significant Other              _______  x $28.00 = $__________

                                                                                                    TOTAL  =  $__________

Mail Payment to:

Janet Potter
1212 W. 15th St.
Davenport, IA  52804

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