Request / Donation Form

You may use this form for the following types of donations/requests. Please review the description and information for each category on the guidelines page.
    o  Artifact Donation
    o  Charitable Donation
    o  Volunteer
    o  Newsletter (membership required)
    o  Membership Pledge
    o  Other (LCHS Wish list fulfillment)

Name:
Address
City State ZIP
Phone:
Email Address
 
Request Type
 Artifact Donation 
 Charitable Donation 
 Membership Pledge 
 Other (LCHS Wish list fulfillment)
 Newsletter
(membership required)
Volunteer Type
 
Membership Pledge
 $15 Student 
 $40 Family/Couple 
 $20 Single Senior (60+) 
 $100 Contributor 
 $25 Individual 
 $250 (or above) Patron 
A membership form will be mailed to the address listed above.
 
Description of Artifact or Wish List items that you would like to donate. If a Charitable Donation, please state the pledged amount of donation and on behalf of what person and/or organization
Please review the guidelines for assistance in filling out this section.
Image Verification
captcha
Please enter the text from the image:
[Refresh Image] [What's This?]
Powered by EMF