Cosmic Kids Club Membership Form

Child's Name: Child's Age: *Second Child's Name: *Second Child's Age: *Third Child's Name: *Third Child's Age: *if nessessary Name: Address: City: State: Select a U.S. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code: Home Phone: Work Phone: Email: Membership cost per child is $65 Total Amount Due: Payment Type: Check*     Visa     Mastercard Name on Credit Card:: Credit Card Number: Exp. Date: Jan Feb March April May June July Aug Sept Oct Nov Dec 2004 2005 2006 2007 2008 2009 2010 *Security Code: What is this?     If you would like to make an additional contribution to the Center, please indicate here and your account will be charged accordingly. *Please make check payable to Virginia Air & Space Center and send to VASC, 600 Settlers Landing Road, Hampton VA 23669 Cash payments should be made in person at the Center YES! Send me more information on other memberships! YES! Put me on the Virginia Air & Space Center email list!

Call Lucinda McDonald at (757) 727-0900, ext. 718 for more information or to purchase a membership

What is a Security Code?
The Security Code is a 3- or 4-digit number listed on the back of
your credit card immediately following your card number.
(On American Express cards, the security code may be on the front.)

This number prevents fraudulent charges to your credit card,
such as someone stealing your credit card receipt
and using that information to make a purchase.