Louisa Arts Center
MEMBERSHIP FORM
___ YES! I want to become a member of the Louisa Arts Center
___ OR ~ Yes! I want to give a Gift Membership to ___________________________
(Name of recipient)
Annual Membership Level is:
___ Individual ($25)
___ Family Includes up to four members ($45)
___ Student/full time enrollment with ID ~ Senior (62+) ~ Artists ~ Teachers ($20)
___ Friends ($100)
___ Supporter ($250)
___ Patron ($500)
___ Arts Angel ($1,000)
New Member’s Name ________________________________________________________
(Membership will be in the name of – please remember this for reservations)
Birth date (__ __/ __ __/__ __)
Address ________________________________________________
City _______________________________ State _____ Zip ______
Daytime Phone (____) - ________ Other _________________
Email __________________________________________________
Family/Dual Members
Name and Birth date
1. ______________________________________________________
2. ______________________________________________________
3. ______________________________________________________
4. ______________________________________________________
*If this is a GIFT MEMBERSHIP, the gift is given by: _______________________________
Address _________________________________ City ____________________ State ________
Zip Code ____________ Daytime Phone: (___) _____ - _________ Email __________________
My check is enclosed in the amount of $ ________. Mail to:
Attn: Membership, Louisa Arts Center, PO Box 2119, Louisa, VA 23093
Office Only: Rec’d on _____
By: __________