Name ____________________________________________
Address __________________________________________
City ______________________________________________
State ________________ Zip _____________________
E-Mail Address ______________________________________
Home Phone Number _________________________________
$20 Student $20 Senior $50 Individual $100 Family $250 Contributor $500 Donor $1000 Corporate $5000 Knight's Circle I do not wish to become a member at this time but I would like to make a donation of $__________________
Gift Membership
From: ____________________________________________
Gift Message: _______________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
Method of Payment
Check Enclosed Visa Mastercard
Name as it appears on card________________________________________
Card Number______________________________Expiration Date__________
Signature________________________________________
Thank you for supporting The Whalehead Club!