MID-HUDSON AREA RETIRED TEACHERS ASSOCIATION PO BOX 294, Blooming Grove, NY 10914
Name: ________________________________
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) $ __________ (first year free for new retirees) Scholarship Contribution $ __________ (All monies when contributed are given out in scholarships) Total enclosed $ __________
