Name of person(s) attending	Adult/Teenager	Child (5-12)	Child (4 and under)

Number of People

   Number of Adults at $12.00 each = 
   Number of Children ages 5 to 12 at $5.00 each = 

   Number of Children under 5 years of age at $0.00 each = 

                      Enclosed is my check for $

MAKE CHECKS PAYABLE TO PENN STATE CLUB OF NORTH TEXAS

MAIL TO: Judy Micklow (address can be found in the NTPSU directory)

or send an e-mail to: psu.club@verizon.net for address info