SELACO Alumni Association Reunion 2025 Registration

Registration Information:   Full Name:_________________________________________________________________   Maiden Name:______________________________________________________________   Mailing address: ____________________________________________________________   City:_________________________________  State:_____________  Zip:______________   TTY:__________________________  VP:__________________________   Text:__________________________  Voice:__________________________   E-mail:___________________________________________________________________   Do you wish to have your name and e-mail listed? Publicly  _______ Private  ________

For staff:   Year worked from:  _____________________  to  _____________________

For Student:   Year graduated:_____________________

Payment:   How many people?  ____________ (Deadline is on or before Sept 25, 2025!) 1 - $20.00 2 - $40.00 3 - $60.00 4 - $80.00 5 - $100.00 Credit card:  Master Card  _____  Visa:   _____Discover:   _____AMEX:   _____ Card Holder Name:____________________________________________________ Card Number:_____________-______________-______________-___________ Expiration Date:______________/________________    CVV:____________ Signature:___________________________________________________________ Note: After the card is charged, the name "DEAFWORKS" will appear on your billing statement. Mail this form to: SELACO Alumni Association P.O.Box 1265 Provo, UT 84603-1265 Web: https://www.selaco.org