Name:

Address:

City:

Province:

Postal Code:

Telehone:

Amount Enclosed:

Individual - $10.00 (for one year) $25.00 (for three years)

Family - $12.00 (for one year) $31.00 (for three years)

I__________________________________ give permission to the Lily Society to publish my name, address, and phone number in the newsletter which will be mailed or emailed out to members only.