On-Line Individual Membership Form

First Name: Middle Initial: Last Name:

Address:

Town: State: Zip Code: -

Home Phone: -- Work Phone: -- Ext.

E-Mail Address:

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Name of Emergency Contact:

Emergency Contact's Phone Number: --

Relationship to you:

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I'm interested in the following :

Producing my own Local Access Show Hosting my own Local Access Show

Operating a Studio Camera Operating a Field Camera

Audio Directing/Switching Non-Linear Digital Editing

Please let me know about upcoming workshops!