WCTV Individual Membership Application

Individual Membership Application

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

First Name Last Name
Mailing Address *

Street Address

Street Address Line 2

City State

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

Month Day Year
Membership Type *

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

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

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