| ____ INDIVIDUAL | $25 |
| ____ FAMILY | $35 |
| ____ NON-PROFIT | $50 |
| ____ BUSINESS | $50 |
| ____ BENEFACTOR | $100 & Over |
Additional TAX DEDUCTIBLE DONATION $_____
NAME:
_______________________________________________________________
AADRESS:
_______________________________________________________________
CITY, STATE, ZIP:
_______________________________________________________________
TELEPHONE:
_______________________________________________________________
CHECK FOR $ ______________ ENCLOSED