ANNUAL MEMBER FORM

ANNUAL MEMBERSHIP FORM

Complete one form PER MEMBERSHIP. Visit molokaiartscenter.org/mac-membership/ for details.

ANNUAL LEVELS AND BENEFITS
*Please note that MAC Affiliate benefits are not included in MAC Membership.

	INDIVIDUAL $45	FAMILY $75	FRIEND $100-$499	PATRON $500+
Monthly Digital Newsletter	*	*	*	*
Personal Invite to Openings, Events, Programs	*	*	*	*
20% Discount on Merchandise	*	*	*	*
20% Discount on Workshops	*	*	*	*
20% Discount on Events (excludes fundraisers)	*	*	*	*
20% Discount on Youth Classes		*	*	*
20% Discount on Affiliate Fees			*	*
Discount on Art Supplies			*	*
2 VIP Tickets to MAC Events				*
VIP Access to MAC Events				*

Family Surname*
Adult Name*

Mr. Mrs. Ms. Dr....First NameMiddle NameLast NameSuffix
Adult Phone Contact*

Area CodePhone Number
Type of Phone*
Adult Alternate Phone Contact*

Area CodePhone Number
Type of Phone*
Main Contact E-mail*

Confirmation Email
Mailing Address*

Street Address/PO Box

Street Address Line 2

CityState

Zip CodeCountry
Are you a (select one)*

Molokai Resident - Full TimeMolokai Resident - Part-TimeNon-Resident - HawaiiNon-Resident - MainlandNon-Resident - International
Molokai Address (if Full or Part-Time)

Street Address/Residence-Hotel/Condo Number

Mailing Address/P. O. Box

CityState

Zip Code

DEMOGRAPHICS

USED FOR REPORTING PURPOSES ONLY
Age group

Adult 18+Senior/Kupuna 65+
Race (you may select more than one; include family members if listed below)

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteHispanicOther
Do you or any of your family members listed below require reasonable accommodation for a special circumstance/handicap? What type of accommodation?

FAMILY MEMBERSHIP

PLEASE ADD INFORMATION ON FAMILY MEMBERS IF NOT INDIVIDUAL MEMBERSHIP (must be in same household).
Adult 2 Name

Mr. Mrs. Ms. Dr....First NameMiddle NameLast NameSuffix
Relationship
Adult 2 Email
example@example.com
Adult 2 Phone Number

Area CodePhone Number
Child 1 Name

First NameMiddle NameLast NameSuffix
Birthdate

MonthDayYear
Date
Child 2 Name

First NameMiddle NameLast NameSuffix
Birthdate

MonthDayYear
Date
Child 3 Name

First NameMiddle NameLast NameSuffix
Birthdate

MonthDayYear
Date
Child 4 Name

First NameMiddle NameLast NameSuffix
Birthdate

MonthDayYear
Date
Child 5 Name

First NameMiddle NameLast NameSuffix
Birthdate

MonthDayYear
Date
Child 6 Name

First NameMiddle NameLast NameSuffix
Birthdate

MonthDayYear
Date

Emergency Contact Information

Who should we contact in case of emergency?
Contact Name*

First NameLast Name
Contact Relationship*
Contact Phone Number*

Area CodePhone Number
Membership Agreement

By checking boxes below, you acknowledge that you have read and understand your Membership Agreement.
In signing below,*

I hereby agree to abide by all rules of the Molokai Arts Center and to support its goals and mission.I hereby release the Molokai Arts Center (and its officers, directors, agents, subsidiaries, joint ventures and employees) from any liability, costs and damages resulting from participation by the above-named individual(s).If I have a dispute with one or more other Members, I shall release the Molokai Arts Center (and its officers, directors, agents, subsidiaries, joint ventures and employees) from claims, demands and damages (actual and consequential) of every kind and nature, known and unknown, arising out of or in any way connected with such disputes.I understand that the Molokai Arts Center shall not sell or rent Member's personal information to third parties without the Member's explicit consent. Molokai Arts Center shall store and process Member information in the United States that are protected by available physical as well as technological security devices. However, the Molokai Arts Center shall be permitted to access and modify Member information with Member's permission.I shall indemnify and hold the Molokai Arts Center (and its officers, directors, agents, subsidiaries, joint ventures and employees) harmless from any claim or demand, including reasonable attorneys' fees, made by any third party due to or arising out of Members breach of this Agreement, or Members violation of any law or the rights of a third party.I understand that this is an Annual Membership. I further understand that I may change my Membership type upon renewal. Renewal is due in the month this form is signed.
Signature*

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Print Name
Today's Date

MonthDayYear
Date

ANNUAL MEMBERSHIP FORM

DEMOGRAPHICS

FAMILY MEMBERSHIP

Emergency Contact Information

Membership Agreement

Payment