Galen Historical Society
Personal Membership / Gift Membership / Donations
(Please check membership level desired)
1. ( ) Family / Individual $ 15.00
2. ( ) Senior(age 62+) - Family / Individual $ 12.00
3. ( ) Student (Thru College) $ 2.00
4. ( ) Patron Level $ 50.00 +
5. ( ) Corporate Level $ 100.00 +
6. ( ) Benefactor / Memorial $ 1000.00 +
City or Town: _________________________________ Zip ________
Email Address: _________________________
Amount Enclosed $ ________________ Date: ________________
Make checks payable to the Galen Historical Society and mail to:
Galen Historical Society / P.O. Box 43 / Clyde, NY 14433
If this is a Gift Membership, please select the level of membership desired and fill in the individual's name and contact information.
Gift Membership from: ___________________________________________
If this is a Donation, please fill in your name and contact information above.
Donation ( ) In Honor of: ( ) In Memory of: ___________________________________________
Do you require a receipt for your donation? ( ) No ( ) Yes
Memberships and Donations are tax deductible under Section 501-C3 of the IRS Code.