Rolling Hills Zoo Online Membership Form

Note: Upon clicking "Submit," you'll receive an email confirmation. Your email confirmation should arrive within the next 30 minutes.

If you do not receive a confirmation email, or receive an error, please contact us at 785-827-9488 ext. 116 (Kathy Tolbert) or email kathy@rollinghillszoo.org so we can confirm and/or complete your registration.

Are you purchasing this Membership as a Gift?*

YesNo

Your (Purchaser) Name*

First NameLast Name

Your (Purchaser) Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Enter your own email address, not the recipient's, here. We will email you a confirmation though this email.*

example@example.com

Is this a New or Renewal Membership?*

NewRenewal

What is the Member #:

Membership Information

This is the information associated with the membership. If this is a gift, you would put the gift recipient's info here.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Area CodePhone Number

Email

example@example.com

If this is a Family, Family Plus or Couple +2 Membership, please list 2nd Cardholder's Name: (if not, skip)

First NameLast Name

If this is a Family Membership, list the Names and Ages of Children. (If not, skip)

Example: Tom - Age 4, Chelsea - Age 8

Would you like to mail this gift membership to the address of the person(s) you are gifting this to?

Yes, please mail it to them.No, mail it to me, please.

Additional Information or Comments:

Membership Purchase:*

Individual Membership$45.00

Individual +1 Membership$90.00

Couple +2 Membership$145.00

Family Membership$145.00

Family Plus Membership$175.00

Supporter Membership$300.00

Caregiver Membership$500.00

Total $0.00

Payment Method

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country