Program Enrollment

Please print this form, complete and mail or fax with payment to:
South Shore Natural Science Center
P.O. Box 429
Norwell, MA  02061
781-659-2559

fax: 781-659-5924

 

My name:
Child's Name (if applicable): Age:    Grade:
Address:
City:   State:    Zip:
Phone:
e-mail:
Check one: Member    Business-Member     Non-Member
Program: $
Program: $
Program: $
Program: $

Total (payable to SSNSC)

$
     
Payment Method: Check or Money Order (payable to SSNSC)
Charge: MC  VISA  Discover
Credit Card #: Expiration Date:
Card Holder Name:
 

Signature of Cardholder: _______________________________________________