I would like to join the CU Physical Therapy Alumni Association!

PLEASE PRINT
Name _________________________________________________________
(as you would like it on your membership card)

Degree ______________ Class Year ____________

Name while in school ____________________________________________
Home Address _________________________________________________
______________________________________________________________
Home Phone ___________________________________________________
Email _________________________________________________________

Occupation/Position Title _________________________________________
Business Address_______________________________________________
______________________________________________________________
Business Phone ________________________________________________

Membership
____ I wish to become an Annual Member for $25.

_____ I wish to become a Lifetime Member for $250. Never pay dues again! You will always be an active member.

_____ I wish to donate $_______ to the:

_____ CU PT Program
_____ PT Rural Scholarship Program

Total Enclosed $__________

Payment Option
___ Check enclosed. (Please make check payable to CU PT Alumni.)
___ Please charge to my: ____ VISA ____ MasterCard
Card # ___________________________________________
Expiration Date ____________________________________
Signature ________________________________________

Please print and return this form with payment to the Office of Alumni Relations, Campus Box A-080, 4200 E. 9th Avenue, Denver, Colorado, 80262, or fax (for credit card payment) to (303) 315-7729. Questions? Please call the Alumni Office at (303) 315-8832 or toll free (877)-HSC-ALUM.

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UCD Alumni Association
4200 E. Ninth Ave., A080 Denver, CO 80262
Phone: 303-315-8832 Fax: 303-315-7729
Toll free: 1-877-HSC-ALUM
Questions or Feedback? Please Contact: alumni@uchsc.edu