Fill in the information below and mail with your Check for $10.00 (made out to Liberty Bell Wanderers) to:

Name: ________________________________________________________

Address________________________________________________________

City, State, Zip________________________________________________

Phone #______________________________________

Single ________ or Family ________________

($10.00) ($10.00)

Received New Walker Kit: _______

Names of others in family: ____________________________________________________

__________________________________________________________________________

_____________________________________________________________________________

I am interested in: Holding Office ________ Helping at Events __________________

Planning Events ____________________