SCTV MEMBERSHIP APPLICATION NAME _______________________________________________________

ORGANIZATION _______________________________________________________

ADDRESS _______________________________________________________

MAILING ADDRESS _______________________________________________________

CITY, STATE, ZIP _______________________________________________________

PHONE ______________(H) ______________(W) _______________(C)

EMAIL _______________________________________________________ MEMBERSHIP TYPE Ο$25 Individual Membership Ο$50 Organizational Membership

Ο$15 Organizational Representative (Organization must be a member) Ο$75 Family Membership (Covers 2 adults and all children under age 18 who reside at the same address)

Member Signature Date _______________________________________________ If under 18, parent or guardian must sign: Parent Signature Date _______________________________________________