1. Civic Association Dues:
2. Landscaping Donation (Optional):

Please complete the following information:

1. Has your information changed since last year?*
   Yes No
2. Do you wish to receive e-mail updates from Worthington Hills Civic Association?*
   Yes No
3. Do you wish to receive email updates from Perry Township?*
   Yes No

1. Street Address:*
2. Phone (xxx-xxx-xxxx):*
3. Last Name:*
4. First Name:*
5. Email:*
6. Last Name:
7. First Name:
8. Email:

Yes, I would like to keep Worthington Hills strong & vibrant by helping out in my community!

1. Name(s):
2. Phone:
3. Email:

Please check any activities you would like to help with:

1. Summerfest
   Serving on a Committee
2. Newsletter
   Serving on Board of Directors
3. Membership Drive
   Neighborhood Communications
4. Holiday Food Drive
   Red Cross Blood Drive
5. Leadership Worthington's Service Day (May)
   July 4th Activities