Please complete this application and send into school with
your child in
an envelope marked “St. Agnes Fathers Club”.
Please don't forget to enclose your membership check for
$25.00 or
supply the required information below to charge your American Express Card.
Name:__________________________________________________
[ ] My information has not changed from the 2005-2006 Membership Directory
Spouse's Name:__________________________________________
Home Phone:____________________________________________
Work Phone:____________________________________________
Cell Phone:_____________________________________________
E-Mail Address:__________________________________________
Home Address:__________________________________________
Village:___________________________
Zip Code:_____________
If you would prefer to pay by American Express Card, please
complete the following:
American Express Card Number:___________________________
Name on Card:_________________________________________
Expiration Date:________________________________________