CMC Membership Application

This is a printable form only. Please fill out the following fields, print the page, sign it, and mail/fax it to us at:

Community Media Center
711 Bridge St. NW
Grand Rapids, MI 49504
Fax: (616) 459-3970

Membership Information

Student/Low Income: $24 Individual: $36 Resident Family: $48
Individual Non-Resident: $60 Non-Profit Organization: $72 Family Non-Resident: $84

Must live at the same address.

3 People - Additional people are $20 each

Name:
Address:
City: State: Zip:

Township:
Email:

Phone: Home Work Cell
Other Phone: Home Work Cell

Payment Method: Amount:$

Membership Type: New Renewal

Main Interests:
Television Radio Wealthy Theatre Media Literacy/Education

Credit Card Account Number: (not sent over the internet)

Expiration Date:

Signature: X ___________________________________________