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PKSCA
Membership Form
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Name____________________________________
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Contribution
enclosed:
___ $500
Corporate Contributor
___ $250 Corporate Sponsor
___ $100 Patron
___ $75 Non-Profit Organization
___ $50
Sustaining Member
___ $25 Family
___ $20
Individual
___ $5
Student
To earmark a donation for a
particular program, please note it on your check or on this
form.
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Address
_________________________________
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City/State/Zip
____________________________
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Telephone
_______________________________
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Fax
___________________________
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Email__________________________________
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Interest areas, proposals, questions:
________________________________________
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Special resources we can offer:____
_________________________________
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