Rough Rider Membership Registration

Membership Benefit Options - all options $350

Medora Musical: Two Season Passes valued at $260 + $90 Tax Deductible Donation
Golf: Two Rounds at Bully Pulpit Golf Course valued at $150 + $200 Tax Deductible Donation
Shopping: $150 TRMF Gift Card + $200 Tax Deductible Donation
Full Donation: $350 Tax Deductible Donation

Benefit Choice

Season Pass Holder 1 (First Name Last Name)

Season Pass Holder 2 (First Name Last Name)

Name(s) as you would like it to appear in the Medora Musical Program

RR Count

Donor Information

First Name

Last Name

Birthdate

Mobile Phone #

Email Address

Street Address

City

State

Zip Code

Country

Would you like to add one or more Junior Rough Rider Memberships?

Yes

Junior Rough Rider

Enter information for an individual child. Click "Add another" at the bottom of this section for each additional child.

Child's First Name

Child's Last Name

Child's Birthdate

Email Address

Donor's Relationship to Child

Parent/Guardian First Name

Parent/Guardian Last Name

Mobile Phone

Street Address

City

State

Zip Code

Country

Child's name as you would like it to appear in the Medora Musical Program

Count

Charitable Contribution

Value of Goods

Total Amount

Payment Information

Name on Credit Card - First Name

Last Name

Card Type

Card Number

Code

Renew My Membership Automatically Each Year

Yes, I agree to have my Credit Card charged annuallyNo, do not automate my renewal

Contact Information