In the spirit of Unity and Fellowship…

Membership Form

Name:_________________________________________

Magickal Name:_________________________________

Which name would you prefer in our directory?_________

Address:_______________________________________

Phone:___________ Email:________________________

Do you want your address and phone kept confidential? ____________________________________________

Memberships:  Individual $20.00 per year, Family (2 adults + any number of children under 18)$30.00 per year.  Make checks payable to Northern Illinois Pagan Alliance.  Print this form, and mail to Northern Illinois Pagan Alliance, 9853 N. Alpine Rd STE 123, Machesney Park, IL 61115, or bring it to any NIPA gathering.  If you wish a receipt, please let us know.