On-Line Membership Application Form

 

First Name:                           MI:          ____       Last Name:                                    

 

(If Any)

Non-Profit Organization, Business or Institution :                                            _    

 

 

Street Address:                                                        ______________              Apt #:                                     

 

 

City, State Zip Code:__________________________________________________                                                                                                

 

 

Phone Number: (Home)  (      )        -                         (Work) (     )       -                   

 

 

CELL: (      )   -                                              Email:                                                            

 

Website Address:                                     

Membership Type (Circle One):             Individual         Organizational         Family

 

For Family Memberships ONLY (Circle One):                  Parent              Child/Teen

 

**If Teen/Child, Parental Permission Signature:                                                                                                                            

 

DATE: ________________________                                                          

 

For Organizational Memberships ONLY  (Circle One):        Delegate    Representative

 

 

Who do we Contact in an Emergency?:_________________Phone:__(      )_________

 

**I give permission to have my name & phone number to other Producers for crew calls:   Yes    No 

 

  East Bridgewater Community Television,

175 Central Street,

East Bridgewater MA 02333  508-378-4298         

                                                                                                                                               

************************For Official Use Only*****************************

 

Membership Fee: $                                       Expiration Date:                                           

 

Membership:                          Approved                    Disapproved

 

If Disapproved, Reason: