GOLD COAST SCIENCE NETWORK

2009-2010  Membership Form

Name :_____________________________________________________________
          (  ) new member       (  ) renewal           (  ) update changes

Mailing Address: _____________________________________________________

City: _____________________________________          Zip: _________________

Phone:  Home: (______) _____________________________

            Work: (______) _____________________________

             Email:  ______________________________________________________

             FAX: (______) _____________________________

Areas of Interest: _____________________________________________________

School/Business  _____________________________________________________

District: ____________________________________________________________

I am willing to help with:

(  ) anything!           (  ) phone tree          (  ) event planning

(  )newsletter          (  ) publicity              (  ) fund raising

(  ) hospitality/decorations       (  ) science fair

(  ) ________________________________________________

Are you wiling to have your name, school/business, phone,
email, and interest printed in the GCSN directory?  Y   N

Please send this form with a check for $10 payable to :

     Gold Coast Science Network
     Debbie Bereki
     P.O. Box 390
     Fillmore, CA 93016