SPACESHIP DISCOVERY MEMBERSHIP APPLICATION

Please refer to the SPACESHIP DISCOVERY membership link for a description
of our membership categories.

Today's Date: ___________________

My Contribution is for:

New Membership	Renewal
Gift (See Below)	Donation

Please Check Membership Category: See our web site for further details

Category	Fee	Description
Teacher	$20.00	Admits 1 certified teacher, find out more!
Individual	$45.00	Admits 1 individual and 1 guest.
Grandparent	$55.00	Admits 2 grandparents & 2 of their grandchildren
Family	$65.00	Admits 2 adults & their dependent children.
Family Plus	$80.00	Family Membership, plus 1 named guest
Supporting	$100.00	Family or Grandparent Membership, plus 1 guest.
Sustaining	$250.00	Family or Grandparent Membership, plus 2 guests.

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:_________________________________________________

______________________________________________________________

I would like to share the joy of learning at the SPACESHIP DISCOVERY with a........... ( please check the box)

 ______ Scholarship Membership Donation

# of scholarships_________@$40 each  Total $______________

 ______ Gift membership to the following:

Choose a level _________$60  _________ $75
________ $85  ________ $100
Name:_________________________________________________
Address:_______________________________________________
City:__________________________________
State:_____________________ Zip:____________________

Please send renewal notice to: ______Myself ________Recipient

Payment:

Member Donation Total

$ ________________ $ ________________ $ ________________

Cash

Check

Credit Card (MC/VISA)

____________________________________ ______________
Card Number Exp. Date

Signature: ___________________________________

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

Thank you for supporting the SPACESHIP DISCOVERY!
Please return this form with payment to:

The SPACESHIP DISCOVERY Science and Technology Center
P O Box 532
Hyde Park, NY 12538

If you have any questions please feel free to call 845-229-2438
or email flholt@spaceshipdiscovery.com


Office Use: ______Newsletter __________Card Exp. Date _________Initial