Join Boston Mobilization

Name _____________________________________________________

School (if applicable) _________________________________________

eMail _____________________________________________________

Phone ____________________________________________________

Address ___________________________________________________

__________________________________________________________

Areas of Interest _____________________________________________

__________________________________________________________

I Want to:

___ Be an Intern

___ Volunteer

___ Make a donation and become a member

Donation

___$500 ___$200 ___$100 ___$50 ___$25

Please make checks payable to Boston Mobilization

Notes

Please fill in this form, print it out and send it (with a check, if necessary) to:

971 Commonwealth Avenue,
Suite #20,
Boston, MA 02215

Thank you for your support.