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Last Hope Loyalty Club
Name
*
First Name
Last Name
Email
*
Verify Email
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Phone
*
Amount
*
$200
-
Champion Level
$50
-
Defender Level
$25
-
Advocate Level
Donation Schedule
One Time
Yearly
Continue donating until
(mm/dd/yyyy)
Decal Option
*
Adopter
Supporter
Loyalty Club T-Shirt Size
(For Defender and Champion Levels)
Small
Medium
Large
X Large
2X Large
3X Large
Loyalty Club T-Shirt Color
Dark Gray
Red
Add 3% to my total amount to help cover the payment processing fees
