Churchville Nature Center
Membership Application
|
Churchville Nature Center |
|
|
NAME
|
________________________________________ |
|
ADDRESS
|
________________________________________ |
|
________________________________________ |
|
|
CITY
|
________________________________________ |
|
STATE
|
______ |
|
ZIP
|
_________________ |
|
PHONE
|
(home)___________________(work)___________________(cell)___________________ |
|
EMAIL
|
________________________________________ |
Membership Fees (Check One):
|
[ _ ] Individual $18.00
|
[ _ ] Family $29.00 |
| [ _ ] Senior Citizen Individual $15.00 | [ _ ] Student $15.00 |
| [ _ ] Senior Citizen Family $21.00 |
Total Amount: $_________________
Join at a higher giving level and receive full family benefits & a one time nature center gift certificate!
| [ _ ] Mallard $50+ |
$10 gift certificate |
| [ _ ] Blue Heron $100.00+ | $20 gift certificate |
| [ _ ] Osprey $250.00+ | $50 gift certificate |
| [ _ ] Dragonfly (life) $1000.00+ | brass member card and name on life members plaque |
Payment Option:
____check (payable to Churchville Nature Center)
____VISA / Mastercard
Number __________________________________ Exp ___________
Signature ________________________________________________
Send this form to: Churchville Nature Center, 501 Churchville Lane, Churchville, PA 18966
Thank you for your support!