Passing on the Tradition

Support Group

2010 Membership / Sponsor Form

Date ___/___/___

 All memberships are for one year (Jan. 1 through Dec. 31)

(Please print the following information)

 Name: __________________________________________________________

Address: ________________________________________________________

City: ______________________________ State: ______ Zip. ______________

Phone Number (______) ______-___________ 

E-mail address _____________________________________

Type of Membership (Please check one)

Individual or Family $10.00 ____ Club & Organization Affiliate $25.00 ____

I would like to volunteer to be my State Support Group Representative ____

Type of Sponsorship (Please check one)

Individual and Grant Sponsorship $____________

Small Business Sponsorship $250.00 _____   Corporate Sponsorship $500.00 _____

Make membership payment payable to Support Group (Membership)

Make sponsorship payment payable to Support Group (Sponsor)

Send check or money order and completed 2010 Form to:

     Support Group

     1035 Doe Haven Rd.

             Ekron, KY 40117