Membership Form

Membership Registration

Membership Year: January-December 2010

Membership Donation: (Please Circle)
$5,000 and Up - Benefactor
$1,000 to $4,999 - Sustainer
$500 to $999 - Champion
$200 to $499 - Guardian Angel
$100 to $199 - Friend
$50 to $99 - Helper
$_____Other

Name:
Title:
Organization/Company:
Address:
City, State, Zip:
Phone (work): (home):
FAX: (home / work please circle)

E-mail:(home / work please circle)

Please return your tax deductible membership contribution and completed form:

Children's Coalition of the Lehigh Valley, Inc.
PO Box 1529
Bethlehem PA 18016-1529

The Children's Coalition is always looking for new board and committee members. Are you interested in becoming involved? If so, please indicate here: