Please print out this
form (along with your payment) and bring directly or mail to Lifelong at 119 West Court Street, Ithaca.
We accept VISA, DISCOVER, AMERICAN EXPRESS and MASTERCARD for your convenience. Either come to the center, mail in or pay by phone.
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Yes, I/we would like to become a member of Lifelong.
(PLEASE PRINT)
Individual Member o $20
Household Member o $30
Additional Gift (Additional tax-deductible gifts are appreciated.) ______
Total _____
Name 1_______________________________ Birth Date __________
Name 2_______________________________ Birth Date __________
Address__________________________________________________
City_________________________ State ____ Zip________________
Phone _______________________ Email_______________________
Please send me information on the Ron Havard Society (planned giving). ____
Town/Village/City of Residence (versus your mailing address):
o Caroline o Danby o Dryden o Enfield o Groton o City of Ithaca
o Town of Ithaca o Lansing o Newfield o Trumansburg o Ulysses
o Cayuga Heights o Other ______________
Please make checks payable to Lifelong and mail or deliver to: Lifelong, 119 West Court St., Ithaca, NY 14850
Or ____ MasterCard ___ VISA ___ Discover ___ American Express
Card # ________________________________ Exp. Date_____________
Security Code (3 numbers on back of card) _____