LIBA-D Membership Form

Application & Demonstration of Intent
Let's Involve Beautiful America in Developing Coalescence
"A Multiracial, Bi-County, Human Rights Organization To Unify All People"

Please fill out, print, and mail this application to:

JELLYBEAN THEATRE COMPANY, LTD.,
P.O. BOx 491, Commack, NY 11725

I am interested in engaging in the Jelly Bean Theatre Company's Program
for my school district and/or other special event. My intent is to schedule for
the number of programs as listed below:

General Information

Title	First Name*	Last Name*

Company Name

Address*

City*	State*	Zip/Postal Code*

Phone Number (home)	Phone Number (business)

E-mail*

Website*

* * *

Jelly Bean Program

Please indicate the number of Elementary, Junior High, and High School in your district:

Elemntary : Junior High : High School:

The total number of students in the following grade categories are:

K-2 : College -1st Year:
Grades 3-5: College -2nd Year:
Grades 6-8: College -3rd Year:
Grades 9-12: College -4th Year:

Please indicate the number of performances wanted for each grade category.
Explain how you intend to divide them in your school:

Have Questions?