Membership Application Form

 

Student

 $25
Senior $25
Adult $35
Family $55
Business $75
Patron $100
Benefactor $250
   
Donation ___________
 
Name ______________________________________________________________

Address ____________________________________________________________

City _____________________ State ____________ Zip ______________________

Phone (___)___________________ Email _________________________________

 
Method of Payment  cash
   check
   credit card
   card number ______________________________________________
   exp. date ____/____
 

Mail to or drop off at:
Maude Kerns Art Center
1910 E. 15th Avenue - Eugene, Oregon 97403