Name: _________________________________________________________________
Father’s First Name Last Name
_________________________________________________________________
Mother’s First Name Last Name
Mailing Address: ____________________________________________________________
Street or P.O. Box
____________________________________________________________
City, State, Zip
Father’s Phone: Mother’s Phone:
_____________________________ _____________________________
Home Home
_____________________________ _____________________________
Work Work
_____________________________ _____________________________
Cell Cell
Father’s Email: Mother’s Email:
___________________________________ ___________________________________
Name: _______________________________________________________________________
First Name Nickname Last Name Birthday
USMA Class of________________ Male___ Female___ WP P.O. Box ___________________
(after assigned)
I/We hereby apply for membership in the West Point Parents’ Club of Washington. I/We have enclosed dues payment of $150.00 (see page 2). This will cover ALL 4 years of membership on a non-refundable basis. I/We consent to have our names and key contact information appear on the Club membership roster and /or permit release to interested (non-commercial) parties connected to the Academy or the Club.
Father’s Signature: _______________________________________ Date: _______________
Mother’s Signature: _______________________________________ Date: _______________
PAYMENT INFORMATION
There are two options for payment. You may pay by check or by credit card using VISA, MasterCard, American Express or Discover. Your credit card will be billed through PayPal and will show on your statement as West Point Parent Club-WA. Your credit card information will NOT be shared with anyone nor will your information be made available at a future date to any person. Please call or email Craig Peterson, WPPC-WA Treasurer at 206-801-7551, wppcwa@gmail.com if you have any questions or concerns regarding payment options.
Tax-deductible 4-year membership dues* $150.00
Additional tax-deductible contribution* $_____________________
Total $_____________________
*West Point Parents Club of Washington is a registered non-profit, EIN 26-0685436.
Pay by: ______ check (payable to WPPC-WA) _________ Credit Card
Card type _______ Visa ______ MasterCard _______ AMEX _______ Discover
Card number ______________________________________________________
Expiration date ___ / ____ Security code ______
Name on card ______________________________________________________
Address 1 _________________________________________________________
Address 2 _________________________________________________________
City ______________________________________________________________
State __________ Zip ______________
Please mail this completed form to:
West Point Parents Club of Washington
17559 12th Avenue NW
Shoreline, WA 98177-3807