Principia Club Membership Form

Club Name	Please select your Principia Club:
First Name
Middle Name
Last Name
Phone Number
Address*
City
State
ZIP
Country
Email

Spouse First Name:
Spouse Middle Name:
Spouse Last Name:

Names of children (up to the age of 20)

Child 1 First Name:
Child 1 Last Name:
Child 1 Nickname:
Child 1 Age:
Child 1 Grade:

Child 2 First Name:
Child 2 Last Name:
Child 2 Nickname:
Child 2 Age:
Child 2 Grade:

Child 3 First Name:
Child 3 Last Name:
Child 3 Nickname:
Child 3 Age:
Child 3 Grade:

Child 4 First Name:
Child 4 Last Name:
Child 4 Nickname:
Child 4 Age:
Child 4 Grade:

Membership Dues:

Individual ($25)

Family ($35)

Recent Grad ($15)
(within the past 5 years)

Contribution to club:
(Dues do not cover all Club expenses)

$

Travel Fund:
(This fund helps local prospective students visit Principia)
$

Total:
$

Contact the Principia Alumni & Field Relations Office with any questions, 1.800.218.7746 ext. 3146 or field@principia.edu

Donations and dues are tax-deductible.

* If this address differs from your credit card billing address, you may change
it later when you enter your credit card information.

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