| JACKSON PREP BOOSTER CLUB |
| P.O. Box 16117: Jackson, MS 39236 |
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| NAME (S) |
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| ADDRESS_____________________________________________ |
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Residence Address |
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State |
Zip |
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| RES.
PHONE__________________________________________ |
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| BUS.
PHONE__________________________________________ |
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| TYPE OF MEMBERSHIP |
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| SUPER
PATRIOT ($2,500)_____ |
PATRIOT ($1,000)_____ |
| PLATINUM
($500)_____ |
RED ($250)_____ BLUE ($100)_____ |
| WHITE
($10-$50)_____ |
GOLD-Grandparents ($300/Couple)_____ |
| GOLD-Grandparents
($200/Single)_____ |
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| Shirt
Size/Men's: M L
XL 2XL 3XL |
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