Full Name

Street
Address

City

State    

Zip Code   

Email Address

Home Phone

Alternate Phone      

Phone Type:              Cell N/A Work Pager

Are you a full-time College Student?            Yes No

If yes, college where you are enrolled FULL TIME:               Not Applicable University of Delaware Delaware State University Goldey-Beacom College Wesley College Widener University-Delaware Campus Wilmington College Delaware College of Art and Design Penn State Delaware Technical and Community College University of Maryland Other

If "other", name of College or University:              

Availability

Do you have an interest in being an active Committee Member? 

  Yes No   If yes, which one?

  Events Committee N/A Facilities Committee Membership Committee Other (Please Contact me to Discuss)

Interests

Please tell us about your area (s) of expertise, hobbies or interests and what the types of events and/or activities you would like the Center to offer.

 Response Requested, or enter "n/a" if appropriate.

For how many months would you like to purchase membership?    1 2 3 4 5 6 7 8 9 10 11 12 Not Sure Yet, Please Contact Me

(Membership dues=$10 per month or $5 per month if you are a FULL TIME college student)

How did you hear about Lillith Grove Women's Center?  Another Member Referred Me Received a Copy of the GEAR Report via Email Message Board at Yahoo Groups Word of Mouth Other

Upon clicking SUBMIT below, your information will be submitted to our Membership department.  You will be contacted about making payment arrangements for your membership.

THANK YOU!