$10 Student Memberships (full-time students)

$20 Individual Memberships

$40 Organization Memberships

$100 Patron Memberships

STUDENT/INDIVIDUAL OR PATRON SECTION

First Name:               

Last Name:               

Mailing Addres:        

City, State and Zip: 

E-Mail Address:      

Phone Number:       

ORGANIZATIONAL OR PATRON SECTION

Theatre Name:      

Theatre Address:    

City, State and Zip:  

Phone Number:       

Theatre's Web Address: 

Please make your check out to:   MoACT 
and mail your check to:  Regina Divine
                                         812 Oregon Street
                                         Jefferson City MO 65109