MHCM MEMBERSHIP APPLICATION

Please refer to the MHCM Membership link for a description of our membership categories.

Today's Date: ___________________

Please Circle: My
Contribution is for -		 New Membership Renewal Donation Gift (See Below)

Please Circle: Membership Level $70 Family $85 Family Plus $100 Reciprocal ASTC/ACM $25 Specialist $40 Scholarship Membership

Member Information (please print clearly)

  Ms.   Mrs.   Mr.   Dr.   Mr. & Mrs.

Name:_________________________________________________________________

Address:______________________________________________________________

City:______________________________State:_________________Zip:______________________

Home Phone:_____________________________ e-mail:__________________________________

Name and Ages of Children:__________________________________________________________

Giving a membership gift. Please send a gift membership to the following family:
Choose a level _________$70  _________ $85 ________ $100

Name:_________________________________________________

Address:_______________________________________________

City:__________________________________

State:________________ Zip:___________Telephone:____________
Please send renewal notice to: ______Myself ________Recipient

Circle payment type: Cash Check Credit Card (MC/VISA)

__________________________________________________ Signature: ___________________________________
Card Number/ Exp. Date

My Company ( or spouse's) has a matching gift program. Name of company ______________________________

Thank you for supporting the MHCM! Please return this form with payment to:
Mid-Hudson Children’s Museum, 75 North Water Street, Poughkeepsie, NY 12601
(845)471-0589 fax:(845)471-0415

Please note: When mailing or faxing your membership application, please allow 2-3 weeks for processing time.