Membership Application or Renewing Membership - Please print and mail to the address below. Thank you!
Date:________________________
Mr./Mrs./Ms. ______________________________________________________________
Street Address: ___________________________________________________________
City: _________________________________ State: _________ Zip: ___________
Phones: Home [night]___________________ Day [work]___________________
Cell______________________
E-Mail: _______________________________________
Current Membership No. (if renewal): ________
Regular Annual Membership
Regular Adult, $30.00 ____
Youth with Crises, $15.00 ____
Youth w/out Crises, $10.00 ____
Annual Corporate, $5,000.00 ____
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Lifetime Membership
Junior Life - (date of birth) ___________________ $100.00 _____
Bronze Life - (date of birth) ___________________ $400.00 _____
Silver Life - (date of birth) ___________________ $750.00 _____
Gold Life - (date of birth) ___________________ $1,500.00 _____
Diamond Life - (date of birth) ___________________ $2,500.00 _____
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