Enrollment Form
Please print this form, fill it out and send it along with appropriate membership fee to: UCAC, PO Box 611, Hurley, NY 12443
Questions?
Call: 845-339-9935 or email: info@ulstercountyartscouncil.org

Name
 ___________________________________________________
Company/Organization ___________________________________________________
Mailing Address ___________________________________________________
City / State / Zip ___________________________________________________
Phone / Fax ________________________ / _________________________
Email / Website ________________________ / _________________________
Date ___________________________________________________

Artistic Discipline (please check appropriate category)
Animation
 Architecture
 Art Therapy
 Art Critic
 Crafts
 Dance
 Gallery
 Design
 Digital		 Drawing
 Education
 Illustration
 Installation
 Literature
 Movies
 Museum
 Music
 Painting		 Performing
 Performing
 Photography
 Poetry
 Pottery
 Print Making
 Publications
 Resource
 Radio
 Sculpture
 Television
 Theater
 Visual Arts
 Web Design
 Writers Resource
 Writing
 Other:
___________________

MEMBERSHIP LEVEL (please check membrship choice)
BASIC LEVEL (ineligible for health/dental insurance and certain other benefits) $30
ENHANCED INDIVIDUAL $45
HOUSEHOLD (family) $60
BUSINESS:
       1-10 Employees $75
       11-25 Employees $100
       25+ Employees $150
NOT-FOR-PROFIT ORGANIZATIONS (by annual budget):
       less than $100,000 $60
       more than $100,000 $90
Note: Business and not-for-profit levels of membership receive three (3) enhanced level memberships, eligible for health/dental insurance as employees of the business or organization. Additional enhanced individual memberships may be purchased for $35 each - a $10 savings per person!
Are you interested in health insurance coverage with us?    YES    NO
Are you interested in dental insurance coverage with us?    YES    NO

If "Yes", and you are a household, business or organization, who would be covered besides yourself?
___________________________________________________________________

Would you like to be listed on our website's Membership Directory?    YES    NO

Please be aware that your UCAC membership must be kept up-to-date in order to maintain uninterrupted health/dental insurance coverage!

Thank you for your membership and for your support!