The Prairie Crossroads Blues Society
Membership Application

Please print out, complete the form and mail it to the address noted below.

Name ___________________________________________ Start Date ___________________

Is this a Membership Renewal? ___ Yes ___ No; Please update any contact info that's changed

Address ________________________________ City _______________________ Zip________

Phone # ______________________ Email Address _________________________

Would you like to Volunteer? YES_______ No______

___ Education ___ Entertainment ___ Marketing

___ Membership ___ Newsletter ___ Website/Technology

Membership Types:

Individual ($20/Yr)_______

Family ($25/Yr)_______ Name _________________________

Name _________________________

Name _________________________

Student ($10/Yr) _______

Band ($50/Yr) _________

Corporate ($100/Yr)_______ (includes 4 memberships)

Name _______________________ Name _______________________

Name _______________________ Name _______________________

Make checks payable to:
Prairie Crossroads Blues Society

Mail to:
Prairie Crossroads Blues Society

P.O. Box 8652

Champaign, IL 61826-8652