WCTV Individual Membership Application

Individual Membership Application

The following membership rates are effective as of July 1, 2022
Member Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone*
E-mail*
Age Range*
Birthday

MonthDayYear
Membership Type*

Student $10.00Individual $25.00Family $50.00
Additional Family Member Name

First NameLast Name
Would you like to make an additional donation?
Enter Donation Amount
Total
Total Amount Due

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