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Date________

Choose membership class:

___ Single Membership $20 .00      ___ Family Membership $25.00
___ Supporting Membership $50    ___ Sponsoring membership $100
___ New Member                                ___ Renewal

How did you hear about the Broward Folk Club ?

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___ Newspaper

___ Radio

___ Web site

___ Other___________________

Please enter your personal information:

Name:_____________________

Birthdate:___________________

Second Name (for family membership): ____________________

Second Birthdate (for family membership): ______________________

Address:______________________________

City, State Zip ___________________________

Phone (Daytime):_____________________

Phone (Evening):_____________________

E-mail Address: _____________________

Complete and mail with your payment to:

Broward Folk Club
c/o Elyse Brunt
2503 Wilson St.
Hollywood, FL 33020