WILDLIFE REHAB, INC MEMBERSHIP FORM
| NAME______________________________ |
| ADDRESS____________________________________ |
| HOME#___________________________ |
| WORK#___________________________ |
| EMAIL_______________________________________ |
| Memberships Available |
Individual $12 * Family $15 |
Patron $25 * Sponsor $50 |
| Would like information about wildlife rehabilitation classes? |
| __ YES __NO |
| Print this form and Mail To: |
Wildlife Rehab, Inc. |
| P.O. Box 24552 |
| Winston-Salem, NC 27114 336-785-0912 |