Please enter the name you used in school:

Please enter your Email address:

Please enter the name you use now.

If applicable, please enter your married last name:
(this may seem redundant with the one above but sometimes it is hard to tell:

If applicable, please enter your spouse's name or your partner's first and last name.

Please enter your street address:

Please enter your mailing address (if different)
(include city, state and zip):

Please enter your city:

Please enter your state:

Please enter your zip code:

Please enter your home phone:

Please enter your work phone. If you've retired, let me know to delete your old business number.

Please enter any other phones you wish to list:
They can all go on the same line:

Are you retired?

  Yes

  No

  Sorta

If you have any websites you would like listed on our roster list, please list them here. (Please, no porno sites.)

What else would you like to tell us about yourself? If retired, what occupies your time?

May we post this info on the PGHS Class of 1966 WEB site?

  Yes

  No

What info listed should we not put on the WEB site?
(i.e., Please don't list my phone number.)

Your name please if being filled in by other than the class member:

In order to find you in the future please fill in the information about someone who may know how to find you in 5 years. At this point in our lives, it may be time to use a child or someone else instead of our parents.

Please enter the name of the person that may be able to find you in 5 years:

Please enter their street address:

Please enter their mailing address (if different) - (include city, state and zip):

Please enter their city:

Please enter their state:

Please enter their zip code:

Please enter their home phone:

Please enter their work phone:

Please enter their email address: