Churchville Nature Center
Membership Application


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!