Hall of Fame Club Form

Annual Membership Levels

Donation Amount

Please indicate the amount you'd like to contribute.

Just include the dollar amount - no symbols (ie: 50)

First Name

Last Name

Street Address

City

State

Zip Code

Phone Number

Referred by (If applicable)

Shirt Size

** Student level members and donations over $100 receive a shirt.

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Cardholder Name

Credit Card #

Expiration Date

Security Code

Billing Zip Code

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged