| THE VIATOR CLUB NEWSLETTER | Page 7 of 7 |
| Full Name | . |
| Maiden Name | . |
| Preferred Title | Mr. Mrs. Ms. Other |
| Mailing Address | . |
| . | . |
| City / State / Zip Code | . |
| Telephone(s) | . |
| e-mail address | . |
| Alimni? | No / Yes Year |
| Please circle choice | No - School Parent? Teacher? Other |
| . | . |
| High School Attended | . |
| Year of graduation | . |
| College(s) Attended | . |
| . | . |
| Spouse's Name | . |
| St. Viator Alumnus? | Yes / No |
| Any brother and sisters St. Viator Alumnus? | Yes / No |
| Names / Year (if known) | Contact Information (address, telephone, e-mail) |
| . | . |
| . | . |
| . | . |
Dues and Donations
| Annual Dues | Full - $25.00 | . |
| . | Student - $10.00 | . |
| . | . | . |
| Fund Donations | School Beautification | . |
| . | Extracurricular | . |
| . | Scholarship | . |
| . | . | . |
| Total | . | . |
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