ASSISTEENS® OF IRVINE
MEMBERSHIP RENEWAL INFORMATION FORM
2012-2013
Assisteens Name:_____________________AGE:_____Birthdate:________
Address: _______________________ Zip: _____Home#____________
Email: __________________________cell #_____________________
Grade in Sept. 2012: _____School__________________________
Mother’s Name: ________________________Member of ALI: ____
Mother’s e-mail:____________________ Mother’s cell #_______________
Father’s Name: ____________________ Father’s cell#________________
Siblings Names and Grades (2012): ________________________________
ASSISTEENS® ACTIVITIES
Governing Body Positions held: _________________________________
Committee Chair Positions: ________________________________
____________________________________________________
Philanthropies in which you have participated:
7th:______________________________________________
8th:______________________________________________
9th:______________________________________________
10th:_____________________________________________
11th:______________________________________________
SCHOOL ACTIVITIES (clubs, sports, student government, academia, music, drama, etc)
__________________________________________________________________________________________________________
EXTRACURRICULAR ACTIVITIES (hobbies, interests, religious activities, talents)
__________________________________________________________________________________________________________
PLEASE MAIL TO Kristin Luchetta, 5 Sharpsburg, Irvine, CA 92620
$100 ($50 member dues, $50 senior recognition)
PAYABLE TO ASSISTEENS®
Membership will be considered late after April 1, 2012
($10 late fee after 4/1/2012)