MEMBERSHIP FORM

2WYR 92.5FM, MVH-FM Inc, Youth Radio Southern Highlands

Submit the form below for Membership in 2WYR 92.5 FM Community Radio

There is a 12 month introductory Membership Fee of $15 due within 60 days.

* Required

Title

First Name *

Last Name *

Email Address *

Home Address *

City *

State *

Zipcode/Postcode *

Country *

Mobile Phone Number

Home Phone Number

Work Phone Number

Date of Birth *

Parent or Guardian Permission *
I am 18 years or older (no permission required)
I'm 17 or less (permission required)

Parent/Guardian Name (if required)

Parent/Guardian Phone No (if permission required)

Parent/Guardian eMail (if permission required)

Enter Word Verification in box below *

In registering for membership of 2WYR 92.5 FM Community Radio, I agree to abide by:

A copy of the above rules are available from our Station Manager.