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: _____________ @
_______________= __________
Number of telescope kits:
________________ @ $ 10.50 __________=__________
Processing fee for school vouchers: $ 10.00
____________________ = _________
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. You may call the
MSAS office at (909) 336-1699 to confirm availability
prior to sending this form.