Science Museum of Western Virginia
Membership Form

Please print out this page, fill it out and return it to renew or to join. It should take approximately two weeks to receive your cards.

Please complete form and mail to:                         or fax to: 540/ 224-1240
Memberships
Science Museum of Western Virginia
One Market Square
Roanoke, VA  24011

[  ] Family: $55, a membership for 2 adults and their dependent children through age 23

[  ] Grandparent: $55, a membership for 2 adults and their grandchildren through age 23. Up to six grandchildren can be admitted at any one time.

[  ] Dual: $55, a membership for two adults plus four one-time guest passes.

[  ] Individual: $35.

Name _______________________________________________________________

Second Adult________________________________________________________

Address_____________________________________________________________

City, State Zip_____________________________________________________

Telephone___________________________________________________________

E-mail (for updates, special events, etc...)________________________

Children______________ _______________

______________ _______________

______________ _______________

Also enclosed is a tax deductible contribution of $__________________

The total amount enclosed $__________________

Make checks payable to: Science Museum of Western Virginia

To pay by credit card, please complete the following:

MasterCard [  ]  Visa [  ]  AMEX [  ]  Discover [  ]

Card Number__________________________________________

Exp. Date________________

Signature____________________________________________