SUSQUEHANNA RIVER ART CENTER

Membership Application for September 2007-September 2008

Name_____________________________________________

Address___________________________________________

___________________________________________

Phone (Home)________________Work__________________

E-Mail Address______________________________________

Medium____________________________________________

--Adult $10.00

--Student $5.00

(18 years or under)

--Family $20.00

(Parents and children under 18)

--Patron $25.00; $50.00; $100.00: __________________