THE PENNSYLVANIA COUNCIL ON THERAPEUTIC HORSEMANSHIP INVITES YOU TO RENEW OR INITIATE A MEMBERSHIP IN 2008 – Membership Year 1/1/08-12/31/08

_____ Individual Lifetime Membership: $500
_____ Individual Yearly Membership: $35
_____ 2008 Pennsylvania Qualified Instructor Fee: $10
_____ Student Annual Membership (includes high school, college & program participant): $20

Name:
Address:
City, State, Zip:
County:
Daytime Phone: E-Mail Address:
Program Affiliation:

_____ Program/Operating Center Lifetime Membership*: $500
_____ Program/Operating Center Yearly Membership**: $50

Program/Center Name (as it should appear in publications):
Address:
City, State, Zip:
County:
Daytime Phone: E-Mail Address:
Contact Name:
*If Lifetime Membership, Individual Lifetime Membership Designee:
**If Yearly Membership, Individual Yearly Membership Designee:

_____ Tax Deductible Donation (PACTH is a 501(c)(3) non-profit corporation): $_______________
Can we list your name in the donor issue of our newsletter? ___________

Supporter…………...Up to $100.00
Patron……………....$100.00-$499.00
Sponsor…………….$500.00-$999.00
Bronze Sponsor.…..$1000.00-$2499.00
Silver Sponsor……..$2500.00-$4999.00
Gold Sponsor….…..$5000.00-$9,999.00
Platinum Sponsor…$10,000 and above

Name:
Address:
City, State, Zip:
County:
Daytime Phone: E-Mail Address:
Program Affiliation:

Total Payment:
Method of Payment: ____ Cash ____ Check (payable to PACTH) _____ VISA ____ MasterCard
Name on card:
Card Number: Expiration Date:
Signature:

                                  Mail form and payment to: PACTH, Ann O’Shallie, 346 Briar Ln., Chambersburg, PA 17202