Joining Brookside 

I would like to support the mission of Brookside Museum by becoming a member.   

----------------------------------------------------------------------------

Your Name: _______________________________________________

Business/School Name:  ____________________________________

Address: _________________________________________________

City/State/Zip: ___________________________________________

Telephone: _______________________________________________

E-Mail: __________________________________________________

_______  Yes, General Electric Matches My Gifts!

Donation Individual Membership Business/School Membership
$15.00 Senior n/a
$25.00 Individual/Dual Senior  School
$35.00 Family  n/a
$50.00 Donor  Corporate 
$ _______ (other) Higher Levels Higher Levels

You must be 60 years or older to qualify for senior or dual senior
membership. 

Payment may be made by check, Visa, or MasterCard.

Visa/MasterCard #: ________________________________________

Expiration Date: ___________________________________________

Signature: ________________________________________________

Date: ____________________________________________________