Please print this form, fill out and return with payment to your Student’s Home Room Teacher

Membership Dues are $5.00 per member

Number of Memberships _________ @ $5.00 each

Amount Enclosed ______________

Make Checks Payable to OPMS PTA

Member Names: __________________________               ____________________________

Address:                   ______________________________________________

                                  ______________________________________________

Student Name: _________________________ Grade: ____  Home Rm Teacher  _________________

Student Name: _________________________ Grade: ____  Home Rm Teacher  _________________