Yorktown Civic Association 2010 Membership Form

Mail To: Bob Littell 2827 N. Harrison St. Arlington, VA 22207 Please include $10 Annual Membership Fee with Form. Make check payable to: Yorktown Civic Association

Name(s) of Members

List all adults at this address that should be listed as YCA Members

Address

Mailing Address

Enter only if not the same as your property address above.

Phone Number(s)

E-Mail Address

Please Help Us By Answering a Few Questions (Optional)

Do you own your home? [ ] Yes [ ] No

Do you have children in school? [ ] Elem. [ ] Middle [ ] High School [ ] No

Are you retired? [ ] Yes [ ] No

What is your occupation? ____________________________________________

Do have access to email and the Internet? [ ] Yes [ ] No

Do you use the parks in the neighborhood? [ ] Weekly [ ] Monthly [ ] Rarely [ ] Never

Do you usually attend association meetings? [ ] Yes [ ] No

Please identify the neighborhood issues that are most important to you (circle 1 if most important or 5 if least important):

1 2 3 4 5 Parks Planning and Maintenance

1 2 3 4 5 School Expansion

1 2 3 4 5 Zoning Issues

1 2 3 4 5 Traffic

1 2 3 4 5 Public Health (e.g. West Nile, etc.)

1 2 3 4 5 Crime and Public Safety

1 2 3 4 5 Economic Development

1 2 3 4 5 Neighborhood Events and Activities

1 2 3 4 5 Neighborhood Beautification

1 2 3 4 5 Other _______________________________________

Would you be willing to serve on an Association committee on these issues? [ ] Yes [ ] No