100/$100 Club
Membership Payment Form
Date
/
Month
/
Day
Year
Date
Membership Status
Existing Member
New Member
Affiliation
Alumni
Current Parent
How Many Children Receiving Bricks?
1
2
3
4
Billing Year
Year 2
Year 3
Year 4
Year 5
Payment Options (Year 1)
$500 (Full Payment)
$100 (Year 1 Payment)
Payment Options (Year 2)
$400 (Remaining Balance)
$100 (Year 2 Payment)
Payment Options (Year 3)
$300 (Remaining Balance)
$100 (Year 3 Payment)
Payment Options (Year 4)
$200 (Remaining Balance)
$100 (Year 4 Payment)
Payment Options (Year 5)
$100 (Remaining Balance)
Payment Options (Year 1) - 1 Child
$500 (Full Payment)
$100 (Year 1 Payment)
Payment Options (Year 1) - 2 Children
$600 (Full Payment)
$200 (Year 1 Payment; $100 per year after that)
Payment Options (Year 1) - 3 Children
$700 (Full Payment)
$300 (Year 1 Payment; $100 per year after that)
Payment Options (Year 1) - 4 Children
$800 (Full Payment)
$400 (Year 1 Payment; $100 per year after that)
Full Name for Brick
Class of
Nominate a Teacher (Full Name)
Department
Full Names for Bricks & Class Years
Help us cover transaction fees?
Yes
No
Subtotal
Transaction Fee Total
Total
Contact Information
Name
*
First Name
Last Name
Company Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Billing Information
Total Due
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( X )
USD
Description
Credit Card
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