I want to adopt the ______________________________

Name: _______________________________________
Address: _______________________________
_______________________________
Phone: ( )________________________
E-mail: _______________________________

Donor Level: (Please check one)

Child $5 ________ $20 _________ $50 ________ $75 _______

$100 ________ $150 ________ $250 ________ $500 ________

Enclosed payment is: Cash ________ Check _______ (payable to Wildlands Conservancy)

Credit card: MasterCard __________ Visa _________ Exp. _____________

Account #: _______________________________________

Name on card: ____________________________________

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Signature: ________________________________________