Name:__________________________________ Family($20)____
Street:________________________________ Individual($10)__
City/State:__________________________
Zip:__________________________
Phone:__________________________
E-mail:__________________________
 
Checks should be made payable to Polish Heritage Club of Wisconsin-Madison.
Send form and payment to Jane Dunn, PHC Treasurer, 7617 Sawmill Road, Madison, WI 53717.

_____ My name, address and phone number may be included in the PHC membership directory.
_____ My name, address and phone number may not be included in the PHC membership directory.