2020 - 2021 Membership/Scholarship Form

​MID-HUDSON AREA RETIRED TEACHERS ASSOCIATION
PO BOX 294, Blooming Grove, NY 10914

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 Home: ________________________________

Street: ________________________________

​Town: ____________________State: _______     Zip:  _________

Home phone: ___________________________

Cell phone: _____________________________

​Emergency phone: ________________________

​Email address: ___________________________

​Date of Birth: _______________ Year retired: ________________
 
District: __________________​Subject/Level taught: ___________

Membership Dues ($10.00)                             $ __________

Scholarship Contribution                                $ __________
(All monies when contributed are given out in scholarships)
Total enclosed                                                      $ __________

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