Membership Form Last name: _______________________________________ First name(s): _____________________________________ Street address: _________________________________________________ Town: ________________________________________________________ State and Zip: _________________________________________________ Daytime phone: (_______)_________________ E-mail (optional) ______________________ Regular categories: Family @ ____$50 for one year or ___$89 for 2 years Grandparent @ ____$50 for one year or ___$89 for 2 years ___Individual @ $25 ___Senior or student @ $20 Supporter circles: ___Darwin @ $75 ___Curie @ $125 ___Galileo @ $250 ___Einstein @ $500 ____Gift membership: (Please write in the membership level and the recipient's contact information.) ______________________________________________________________ ______________________________________________________________ ENCLOSED: Membership Dues $____________ Donation* $___________ TOTAL ENCLOSED: $___________ * Explorit very much needs donations (of all sizes) in addition to memberships. Donations are needed for the following purposes. The Endowment; The Facilities Fund; The Scholarship/Fee Assistance Fund; On-site Public Exhibition Programs; On-site School Programs; off-site Travelling Programs; special equipment; general operations.... If you value Explorit as an educational resource and wish to make a major donation, we would prefer that you let us know so that we can discuss the way in which this might happen to bring most benefit to both parties. _____Please call me.