Pearce Club Card

First Name:

Last Name:

Gender:

Street Address:

City

State

Zip Code

Current Grade:

Select one

Cell Phone

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Your Email Address:

First name of the parent(s) or guardian(s) I live with are:

Last name of parent(s) or guardian(s) I live with are:

Parent's Email Address:

First name of other parent(s) or guardian(s) (if you split time between houses):

Last name of other parent(s) or guardian(s) (if you split time between houses):

Other parent email:

Junior High Brothers/Sisters?

Please list your junior high brothers/sisters name, grade, & school they attend.