Cornwall Central Teachers Association
                                                            P.O. Box 719
                                                Cornwall, New York 12518


TO: CCTA Social/Welfare Committee

From: ___________________________________ (person submitting form)

Regarding: _______________________________ (name of staff person)

Event: ___________________________________ (birth, death, wedding, illness, etc.)

Is above a CCTA member?                      Yes      No

Is the event an ILLNESS?                        Yes      No

Is the member hospitalized?                      Yes      No

Will the member be in the hospital long
enough for flowers to reach there?            Yes      No

If yes, name and address of hospital:

__________________________________________________________

__________________________________________________________

In the event of DEATH in the family:

          Full name of deceased ___________________________________

          Relation to staff person ___________________________________

Memorial donations are to be sent to:

          Name of organization _____________________________________

          Full mailing address of organization:

                   ___________________________________________________

                   ___________________________________________________

Please submit this form to the appropriate person in your building.