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 Veronica Murray at 785-827-9488 ext. 129) or email veronica@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) Phone Number*

Just in case we need to contact you about your order.

Your (Purchaser) Mailing Address*

Mailing Address

Mailing Address Line 2

CityState / Province

Postal / Zip Code

Your email address. (If this is a gift, 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*

Mailing Address

Address Line 2

CityState

Zip Code

Phone Number*

Email (Recipient's Email)

example@example.com • If this is a gift, the receipt will go to YOU the purchaser, not their email.

Second Card Holder's Name: (Does Not Apply to Individual Membership)

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:

Please verify that you are human*

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

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