Stonebelt Stargazers Astronomy Club
Membership and Donation Form

Membership dues are as follows;
$10---Student (elementary, high school, college)
$20---Single Adult
$30---Couple (husband & wife)
$40---Family of 4 (husband, wife and 2 children)

Please write a check for the amount of dues.

Make check payable to: Stonebelt Stargazers and send your remittance to:

Stonebent Stargazers
c/o Bill Johnson
765 South Grandview Drive
Paoli, IN 47454

If more than one person is joining please enclose additional form/s. If making a donation Please fill out form so we can send a receipt to you for tax purposes.



City______________________________ State_______ Zip_______________

Home Phone____________________________


[  ] Membership Dues             [  ] Donation

Enter Total________________________________

The information contained on this form will go into the club directory which is available to club members only; we will not sell our membership list. Donor information is available to club officers only.