MSAS PROGRAM REGISTRATION FORM

Please use this form for Private & Student group programs

 

Yes, I wish to schedule an MSAS Program!

Name of organization: ________________________________________________

Name of contact person: ______________________________________________

Work phone: ___________________ Home phone: ________________________

Address: _________________________________ City: _____________________

State: ________________ Zip: _______________

1. Education Program: grade level: _____ 2. Private Program: YES NO (circle one)


*Program date requested: ___________________ Starting time: _______________

Program topic:_______________________________________________________


I have a current MSAS Classroom Membership. YES NO (circle one)
I would like to purchase an MSAS Classroom Membership YES NO (Renewable in October)

MSAS Membership: ____________________@ _______________= __________
Number of student participants: ___________ @ _______________= __________
Number of adult participants: _____________ @ _______________= __________
Processing fee for school vouchers: $ 10.00 ____________________ = _________
Nonrefundable deposit to hold scheduled date @ $50.00 = _________

Total Amount: $ ____________________


____ Enclosed is a check for the total amount.
____ Enclosed is a school voucher for the total amount, plus processing fee.
____ Charge my credit card for the total amount.

Card type: VISA, MASTERCARD, AMERICAN EXPRESS
Card number: ______________________________________
Expires: ___________________________
Card holder’s name, if different from above: ______________________________
Signature of card holder: _____________________________________________

Please make checks payable to: Mtn. Skies Astronomical Society
SEND form and payment to: P.O. Box 1169
Lake Arrowhead, CA 92352

* You will be contacted at the phone number that you placed on this form to confirm availability of requested program date and time. Please call the MSAS office at (909) 336-1699 to confirm availability prior to sending thi
s form.