Date:
Full Name:
Street:
City:	State: Zip:
Phone(s):
Email:
	(email is mandatory for the Members Only area of the website)
Interests:	supporting member only  on-stage  back-stage    (put an X in all that apply)
Student Member?	Yes   (under 18 years of age)
Additional Family Names and contact info if Family Membership:
Full Name:	Email:
Full Name:	Email:
Full Name:	Email:
Signature:  __________________________________________________________
Parent signature if Junior Member:  ______________________________________
Individual membership: $10
Family membership: $20
Amount Enclosed:

Please print and mail with membership fees to:

Monticello Theatre Association
P.O. Box 81
Monticello, IL 61856

Thank you for joining MTA!