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Membership Form - PFLAG Grinnell-Poweshiek
Please provide the following information for our records. This information will be maintained by the PFLAG Grinnell-Poweshiek Board of Directors and will be shared only with PFLAG National.
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* Indicates required question
Contact Name for Individual or Family membership
*
Your answer
Preferred pronouns
Your answer
Physical mailing address (street, city, zip)
*
Your answer
Email address (newsletters and other updates will be sent via email)
Your answer
Phone number (Optional: this will not be shared outside our group)
Your answer
Membership / Donataion Level
*
$15 - Student Membership (annual)
$25 - Individual Membership (annual)
$40 - Household Membership (annual)
$50 and above - Over the Rainbow Membership (annual membership plus an additional gift)
Donation (no membership). Please note below if this gift is in honor of or in memory of someone so we can note this in our records.
If making a donation in memory or in honor of someone, please provide that information here:
Your answer
Total amount paid
*
Your answer
Form of payment. Write checks to PFLAG Grinnell/Poweshiek; Venmo @PFLAG-GPC; or Paypal to pflaggrinnellpoweshiek@gmail.com.
*
Check
Venmo
Paypal
Other:
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