Yes, I would like to be a member of the Peace Theatre.

*First Name:_____________________________________________________

*Last Name:_____________________________________________________

*Organization or business name (if joining as an organization)

______________________________________________________________

*Address:_______________________________________________________

*City:___________________________________________________________

*Province_________________________________________________________

*Country_________________________________________________________

*Phone:_________________________________________________________

*Email:_________________________________________________________

*Membership levels choose one:

Peace Pal Peace Ambassador $500

__Child $10 __Individual
__Student $10 __Organization
__Senior $10
__Adult $25 Peace Leader $1500
__Family $50 __Individual
__Organization $50 __Organization

Peace Partner $200 Peace Visionary $2500

__Individual __Individual
__Organization __Organization

None of these levels suit you? Be a Peace Rebel and choose your own
amount______________

*Method of payment: __Credit Card__Cheque__Cash (in person only)

How did you hear about us?__________________________________________

Have you participated in our programs?_________________________________