WLDPS 100 Plus Club Application/Membership Form 2016/17

(Walton Le Dale PTA Small Society Lottery Registration SLO103)

Number
Number
Number
Number
Number
Admin use only

I wish to join the WLDPS 100 Plus Club and would like .
Numbers.

I have enclosed cash for .

Name to which number should be allocated, eg The Smith Family, Mr Smith,

John Smith. (Person must be over 18 years of age)
...................................................

How you would like your name to appear on the Wednesday Weekly and list
of winners on the school website. (Person must be over 18 years of age)
..

Prize winnings payment by

Connection to school e.g. childs name and class, teacher or staff member
(ease of administration purposes)

Cash
Cheque payable to
(Please circle preferred method)

..
Contact name ..
Address ...............
Telephone number ...............................................................
Email ...........................................................................
Signature..