ASTRONOMY FOR YOUTH, INC.

Membership Application Form

Date _______________.

Name _____________________.

Date of Birth (optional) __________.

Work Phone ___________ Home Phone __________.

Address__________________________________.

E-Mail Address __________________.

Emergency Contact Person _____________________

Relationship __________ Daytime Phone ___________

Evening Phone ___________

Pertinent Medical Information: __________________________________________.

How did you hear about us? ____________________.

Please list any education, work and volunteer experience, skills or interests that you would like to share. _________________________________________

_________________________________________

Which particular area of astronomy interests you? _____________________________________________________________________________________.

By signing below I agree to adhere to all policies, agreements and responsibilities enforced by Astronomy for Youth, Inc.

Name: ________________________Date: _________