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: __________