| Leadership Gift |
| Yes I want to support my community with my leadership Gift of $____ |
| Funding Category:_____ |
| Membership Levels: |
| Basic Membership: |
Senior Citizens (50+): |
| Student (Adult or Child) $15 |
Single Adult $20 |
| Single Adult $25 |
Married Couple $30 |
| Married Couple $40 |
|
| Family $75 |
|
| President's Club: |
| Member $100-499 |
|
| Honorary Member $500-999 |
|
| Executive Member $1000-1999 |
|
| Crown Club: |
| Bronze Membership $2000-3999 |
|
| Silver Membership $4000-5999 |
|
| Gold Membership $6000-9999 |
|
| Pride of Dorchester: |
|
| $10,000 and Over |
|
| My gift will be paid by: ___Check (enclosed); ___Monthly; ___Quarterly; ___Annually |
| Name: |
Home Address : |
| City : |
Zip: |
| ___ I Wish to remain anonymous |
Signature: |
