Individual and Household Membership Form

Give what you can. We welcome your donation at the suggested levels below, or whatever amount works for you. If you can give more, please do. If you give less, we understand. Every dollar is a direct investment in the Mad River Valley's healthy land and clean water. Prefix: Dr. Miss Mr. Mrs. Ms. Mx. First Name: Last Name: Company: Address Type: Home Work School Other Mailing Address: Address Line 2 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip Code: - Zip Suffix I live in the Mad River Valley: Full time Part time - Winter Part time - Summer Part time - I Come and Go I don't live in the MRV I live in the MRV Town of (full or part time): Duxbury Fayston Moretown Waitsfield Warren I don't live in the MRV Email: Phone: Home Mobile Other Work Are there other people in your household who you would like to also be considered FMR members? If so, please include their names here: Comment(s): Create a Login Name: Login Password: Retype Password: