Check One: [ ] Newspaper [ ] Magazine [ ] Video Production [ ] Newsletter
[ ] Yearbook [ ] Broadcast [ ] Online Media
Title of Medium:______
Frequency of magazine/newspaper publication:______Yearbook distribution month: ______
Video Production:______
Types of productions Production frequency
Online Media:______
Web site address
SCHOOL INFORMATION
School:______
Mailing Address:______
Street Number or P.O. City Zip
School Phone Number: ( ) ______Adviser Extension: ______
School Fax Number: ( )______E-mail Address:______
Principal’s Name: ______Principal’s E-mail: ______
High School or Junior High School Enrollment:______Grades:______through ______
ADVISER INFORMATION
Adviser Name:______Home E-mail:______
Home Address (for emergencies only):______
Street Address City Zip
Home Phone: ( )______Cell Phone: ( ) ______
Number of Years as Adviser:______Years at this School:______
Other Teaching Assignments:______
ANNUAL MEMBERSHIP FEE
$135 per publication. $67.50 per additional publication.
[ ] This is the first publication I am registering for Fall 2016-Spring 2017 OSM Membership.
[ ] I have already registered a publication for Fall 2016-Spring 2017 OSM Membership.
[ ] I am enclosing a check. [ ] Please invoice me.
[ ] Address invoices to me. [ ] Address invoices to:______
______
PO Number (not required) Adviser signature
PLEASE SUBMIT A SEPARATE MEMBERSHIP FORM FOR EACH MEDIA PROGRAM