The Florence Melton Adult Mini-School FMAMS

*Please indicate level of membership:

Founder Individual - $1800

Founder Couple - $3000  Spouse's name

Supporter Individual - $720

Supporter Couple - $1400  Spouse's name

I will make an additional donation in the following amount:

Please bill me for the entire amount
Please bill me in installments

Founder membership may be paid in installments over a three-year period. Supporter membership may be paid in installments over a two-year period.

*First Name:	*Last Name:

*Street Address:	*City:	*State:	*Zip Code:

Country:

*Telephone:	Mobile Phone:

*Email:	Spouse's Email:

*Name of Minischool:	Year graduated:

Yes I'd like to receive newsletters or notices about alumni events