Membership Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

Home Number*

Cell Number*

Are you affiliated with a place of worship?*

YesNo

If yes, which one?

$10-24 – Friend Level – Newsletter and announcements of special events and activities$25-99 – Member Level – DISCOUNT on Adventures in Learning and Senior Center activities$100-249 – Partner Level – One FREE Adventures in Learning course or other activity$250-499 – Sustainer Level – One FREE Adventures in Learning series or two other activities$500-999 – Benefactor Level – Two FREE Adventures In Learning series or four other activities$1,000+ – Founder’s Circle – One FREE YEAR of Shepherd’s Center-sponsored activitiesAdditional donation in memory or honor of someone special to you

Donation and Membership Level

USD*Entering a dollar amount and clicking submit below will take you to our Paypal page to make an online payment. Please consider adding $1 to cover fees incurred by Paypal for processing. Thank you!*

Donation In memory of:

Donation In honor of:

Send acknowledgement to (Name):

(and complete mailing address):

PLEASE notify us whenever your address changes. You can send us the corrected mailing label, or simply call us with the new information.
* We ask for your worship affiliation because local congregations often ask how many of their members are also members and/or volunteers of the Shepherd’s Center.
If you would prefer to mail in your membership donation, simply print out this form and mail it completed along with your check to:

The Shepherd's Center of Greater Winston-Salem
1700 Ebert Street
Winston-Salem, NC 27103
336-748-0217
info@shepherdscenter.org
www.shepherdscenter.org

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