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: