| Name | __________________________________________ |
| Address | __________________________________________ |
| City | __________________________________________ |
| State | __________________________________________ |
| Zip | __________________________________________ |
| Email | __________________________________________ |
Check Amount: |
__ $25 Junior (under 18) or Senior (65 and over)
__ $35 Individual
__ $50 Family
__ $100 Non-profit Organization
__ $200 Corporate
_______ Additional donation |
| Comments | ________________________________________
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