FRIENDS OF BELLINGRATH MEMBERSHIP FORM

                       □ New Membership          □ Renewal          □ Gift 

         

(Mr./Mrs./Ms.)___________________________________________________________

                                                                                                 Date of Birth

(Mr./Mrs./Ms.)___________________________________________________________

                                                                                                 Date of Birth
Address________________________________________________________________

City: _____________________________  State: __________  Zip: ________________

Telephone: ____________________  Email: __________________________________

Children's Names & Date of Birth

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________
 (Family, Patron & Belle Camp memberships may include up to 2 adults
  and 5 children in one household.)

Membership Level                           
General Membership Levels: □ Individual $40       □ Couple  $60      □ Family $100

Patron Levels:                      □ Rose  $150            □ Azalea  $250
Belle Camp Society Levels:    □ Silver $500           □ Gold $1,000      □ Platinum $2,500

Total Amount Enclosed $_________________________

□ Check Enclosed (Payable to Bellingrath Gardens and Home)

□ Visa        □ MasterCard     □ Discover      □ American Express

Credit Card Number: __________________________________Exp. Date: __________

Signature: ______________________________________________________________

Form may be printed and mailed with payment to:
Membership Office
12401 Bellingrath Gardens Road, Theodore, AL  36582
251-973-2217 ext. 165    Fax  251-973-0540