Main Street Connect Activity Memberships
PLUS Membership
CORE Membership
$99 per month per person
$30 per month for the first
household family member and
$15 per month for each additional
household family member
Most program and event fees included
Additional program and event fees
($5-$15 each)
Activity Membership Application
Select your ACTIVITY Membership type:
How did you hear about Main Street?
Family or friend (Note name in Other box below.)
Social media
Internet search
Professional referral (Note name in Other box below.)
Catalogue for Philanthropy
Other (Please share in Other box below.)
If you selected "Other" please share:
What types of programming are you most interested in? (Select all that apply)
If you selected "Other" please share:
Contact Information
First Name:
Last Name:
Email:
Phone 1:
Phone Type:
Home
Mobile
Other
Work
Phone 2:
Phone Type:
Home
Mobile
Other
Work
I want to get text alerts from Main Street for event reminders, weather delays, closures and cancellations.
Home 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:
-
Zip Suffix
Main Street prides itself on being a fully inclusive community. We ask the following questions to ensure that we are staying true to our values, and to meet the requirements of some of our funders.
Birth Date:
/
/
Pronouns:
He/Him/His
She/Her/Hers
They/Them/Their
Other
Are you of Hispanic, Latino, or Spanish origin? (select all that apply)
Not of Hispanic, Latino, or Spanish origin
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Another Hispanic, Latino, or Spanish origin (for example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc.)
Prefer not to answer
What is your race? (select all that apply)
Do you identify as having a disability?
At times, will you be bringing a support person with you to events?
Emergency Contact Information
Emergency Contact Name:
Relationship of Emergency Contact to Client:
Emergency Contact Email:
Emergency Contact Phone Number: