German American Heritage Center
                            Membership Form

Name:____________________________

Address___________________________

City/State/Zip______________________

Phone____________________________

Email____________________________

Indicate your membership option below.

___ Individual $35

___ Couple $45 (2 adults in 1 household)

___ Family $55 (2 adults and all children in 1 household)

___ Grandparents $55 (2 grandparents and grandchildren)

___ Individual Life Member $1000 (or $1500 for 2 adults in 1 household)

Additional gift donation:_________

Total amount enclosed:___________

___ This is a gift membership. This membership is a gift
        to the persons above and was given by:

Name____________________________

Address___________________________

City/State/Zip______________________

Phone_____________________________

Email_____________________________

___ I would be interested in learning about volunteer and/or internship
        opportunities at the Center.

Please make checks payable and remit to :

German American Heritage Center

712 West Second Street

Davenport IA 52802