| Membership Form |
 |
| Please check membership: |
Today's date:___________________ |
Deluxe $130
Museum Traveler $100
Family $70
Family plus Two $100
Grandparent $65
Scholarship Donation $50
Specialist $55 |
| My Contribution is
for: New Membership
Renewal
Gift Membership
Donation |
| Membership Information:
Ms.
Mr. Mrs.
Dr.
Mr. &
Mrs. |
| Name(s): ____________________________________________________________________ |
| Address:______________________________________________________________________ |
| City:__________________________________ |
State:_________ |
Zip Code:_______ |
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| Telephone:___________________________ Email:__________________________________________________________ |
| Please check, Send my events calendar :
By email only
By mail only
By email and mail |
| Membership is a Gift for: |
|
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|
|
| Name:_______________________________________________________________________ |
| Address:_____________________________________________________________________ |
| City:________________________________ State:________________
Zip Code:__________ |
|
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| Telephone:___________________________Email:___________________________________________ |
| Payment:
Cash
Check Credit
Card (MasterCard or Visa) |
| Credit Card:_____________________________________________
Expiration Date: ______________ |
| My Company (or spouse's) has a matching gift
program. Name of company |
| _____________________________________________________________________________ |
| Please return this form with payment to: Mid-Hudson
Children's Museum, 75 N. Water St., Poughkeepsie, NY 12601 |
| Fax the form to (845) 471-0415 |