Form

Address *

Phone Number *

- Area Code Phone Number
E-mail *
Children covered under Membership

Children listed under Family Membership must live in the same household as Cardholders. Please list both first and last names.
Child 1 Name *
Child 1 Birthday *

- Month - Day Year
Date
Child 2 Name
Child 2 Birthday

- Month - Day Year
Date
Child 3 Name
Child 3 Birthday

- Month - Day Year
Date
Child 4 Name
Child 4 Birthday

- Month - Day Year
Date
Child 5 Name
Child 5 Birthday

- Month - Day Year
Date
Child 6 Name
Child 6 Birthday

- Month - Day Year
Date
Child 7 Name
Child 7 Birthday

- Month - Day Year
Date
Child 8 Name
Child 8 Birthday

- Month - Day Year
Date
Membership Information
*

New Renewal
Type *

Family 1-year ($125) Grandparent 1-year ($150)
We offer Add-Ons to your Family or Grandparent Membership.

Nanny Option

You can add a "Nanny" or addtional cardholder who can use your membership with the child(ren) in your absence. This person is named on the membership card and cannot be changed.
*

Add Nanny ($20) Decline
Nanny's Name
Plus 1

You can also add a "Plus 1" if you like to bring a friend or additional family member with you who is not part of your membership. This person can be different for each visit, but is not a cardholder and cannot use the card in your absence.
*

Add Plus 1 ($20) Decline
Total
Total

USD Paypal
Is this a Gift for another Family? *

Yes No
Gift Giver's Name

Gift Giver's Address

Terre Haute Children's Museum