Please print and fill out this form and send it to the address below.
| Please Check One: | |
| __ $20 Individual | __ $30 Family |
| __ $75 Supporting | __ $100 Patron |
| __ $150 Local Business | __ $500 Corporate |
|
__ $1000 Distinguished Benefactor |
__ $10 Student |
| Total Enclosed | $ |
| Name: | |
| Address: | |
| City: | |
| State: | |
| Zip: | |
| Phone: Area Code ( ) | |
| E-mail address: |
| Please indicate your interest in serving on a committee: | |
| __ Membership | __ Workshop/Seminars |
| __ Fundraising | __ Public Relations |
