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St. Louis King of France CYO Membership Profile
2003 / 2004
Date of Birth:
______________________ Telephone#: __________________________
Address:
_______________________________________________________________
City:
_______________________________________________ Zip: _______________
E-mail Address:
_________________________________________________________
School:
______________________________________________ Grade: ____________
Mother’s Name:
_________________________________________________________
Work #:
___________________________
Father’s Name:
__________________________________________________________
Work #:
___________________________
Emergency Contacts
Name: _________________________________________________________________
Phone #:
___________________________
Name:
_________________________________________________________________
Phone #:
___________________________
Paid Dues: __________ Cash
_________ Check
Taken By (Board Member’s Signature):
_________________________________________
Member’s Signature:
___________________________________Date: _____________