First Name

Last Name

Street Address

City State Zip Code

Area Code Phone

Membership Rates

$35/Single-1 seat/production/year

$60/Couple-2 seats/production/year

$20 Active Voting-1 seat/production/year

$20 Youth-1 seat/production/year

Special Donation Amount

Please designate where the donation should be applied.

Apply Donation to:

Please mail form and check to:

Portland Civic Players
P.O. Box 344
Portland, MI 48875

Thank you!