Memorial Hospital

home - volunteers - auxiliary - membership form

MEMBERSHIP FORM

First Name:		MI:
Last Name:
Company:
Address:
City:		State:
Zip Code:
Home Telephone:
Work Telephone:
Fax Number:
Email Address:
Annual Membership Categories		Gold - $1000 Silver - $500 Bronze - $250 Patron - $100 Sponsor - $50 Friend - $25 Junior (18 & under) - $10 Senior (60+) - $10
Method of Payment
I will mail / deliver a check for $ made payable to: Memorial Hospital Auxiliary
Please call me for my credit card information to charge the amount of $ . (I understand that I must visit your office to sign for credit card verification.)
For publication, please list my name(s) as:
Please DO NOT list my name in publications.
Please send me information about volunteer opportunities. I am interested in contributing my time.