|
|
Family
Members/children 18 and under |
| Name:
__________________________ |
|
|
|
|
Name:
__________________________ |
| Address:
_________________________ |
|
Birth Date:
_______________________ |
|
|
|
| City:
____________________________ |
|
Name:
__________________________ |
|
|
Birth
Date: _______________________ |
| State/Zip:
________________________ |
|
|
|
|
Name:
__________________________ |
| Phone:
(____) ____________________ |
|
Birth
Date: _______________________ |
|
|
|
|
|
Name
: __________________________ |
|
|
Birth
Date: _______________________ |
| (
) Annual Membership per person....$15.00 |
|
|
| (
) Family Membership.......................$25.00 |
|
Name:
__________________________ |
| (
) Patron Membership per year.......$100.00 |
|
Birth
Date: ______________________ |
| (
) Life Membership..........................$500.00 |
|
|
|
|
Name:
__________________________ |
| Enclosed
check for $ ___________________ |
|
Birth
Date: _______________________ |
|
|
|
| Make
check payable to: |
|
|
| Kelleys
Island Historical Association, Inc. |
|
|
| Send
to: |
|
|
| PO
Box 328 |
|
|
| Kelleys
Island, Ohio 43438 |
|
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|
