Name:

_____________________________________________________________________________

Street:

_____________________________________________________________________________

City:

_________________________________

State:

_______________

Zip:

___________-_______

Phone:

_________________________________

Cell Phone: ––––––––––––––––––––––––––––––––––––––

E-mail Address:

_________________________________________________________________________________

$ 5.00 - Student

$ 15.00 - Individual

$ 25.00 - Family

$______- Patron