Membership/Donation Form

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

Yes! I want to become a member of the South Shore Natural Science Center.
Please enroll me as a member for one year.

I do not wish to become a member at this time, but would like to make a donation.

Name:

Address:

City:

State: Zip:

Phone:

E-mail:

New or Renewal Membership (check one):

$60 Family
$150 Corporate
$25 Adult Individual

Enclosed is my donation for:

$1,000+ Benefactor
$500+ Patron
$250+ Sponsor
$100+ Friend
Other
Additional gift for general use
Special Project, use for

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