Contact Information

NAME: _____________________________________________________________

ADDRESS: __________________________________________________________

City, State, ZIP:  ­­­______________________________________________________

PHONE: ______________________            EMAIL: ______________________________

I would like to join The Loyola Soccer Club at the:

_______   National Champion Level - $1,250 – Participation at the $1,250 National Champion Level includes a $1,000 tax-deductible charitable gift; the remainder is payment for the specific benefits listed.  Gear Size _____                                                                               

_______   All-American Level - $600 - Participation at the $600 All-American Level includes a $500 tax-deductible charitable gift; the remainder is payment for the specific benefits listed.  Gear Size _____                                                                               

_______   All-Conference Level - $300 - Participation at the $300 All-Conference Level includes a $250 tax-deductible charitable gift; the remainder is payment for the specific benefits listed.  Gear Size _____                                                                               

_______   Supporter Level - $125 – Participation at the $125 Supporter Level includes a $100 tax-deductible charitable gift; the remainder is payment for the specific benefits listed. Gear Size ___

Credit Card Information

                                                                                                                                               
Credit Card (Visa, MC,                                                                        AMEX, Discover                                                                                 Exp. Date                     

Please charge my credit card for the amount indicated in the member level chosen above.

                                                                                                                                     
  Signature                                                                                              Date

Checks are payable to Loyola College-Men’s Soccer-4501 North Charles Street-Baltimore MD 21210
For any additional information please contact Chris McFarlane at 410-617-5409.