Midshipman Name: _____________________________ Company: ______________

USNA Graduation Year: ______     Date of Birth (mm/dd/yyyy): ____________ Email: ______________

USNA Academy Address: P.O. Box ____________________; Annapolis, MD 21412- __________

Parents' Names:           ________________________               ___________________________

Home Address:            ________________________               ___________________________

Home Address 2:         ________________________               ___________________________

Home Phone Number: ________________________               ___________________________

Work Phone:                 ________________________               ___________________________

Cell Phone:                   ________________________               ___________________________

email:                            ________________________               ___________________________

We would be willing to:                     

                                          _____ Write/Edit the Newsletter
                                          _____ Adopt a Plebe Family
                                          _____ Send Care Packages for Halloween/Valentines
                                          _____ Help with Mid Gathering/Summer Picnic
                                          _____ Serve as Officer
                                          _____ Other

Midshipman Information

High School: ________________________    Location: ________________________

High School Activities & Interests: (sports, extracurricular, scouts, school clubs and organizations, band, etc.)

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Naval Academy Activities: _______________________________________________________________

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