Childcare Passport Membership Application
Please print and fill out this form. When completed, please fax or mail the form to:
Duluth Children's Museum
506 West Michigan Street
Duluth, MN 55802
(Fax) 218-733-7547

Date: _______________ 

Daycare Name: ______________________________________________________

Contact Person:______________________________________________________

Address: ___________________________________________________________

City, State, Zip: ______________________________________________________

Phone(s): ___________________________________________________________

Email: ______________________________________________________________

This is a:        Childcare Passport Membership ($30) 
                        Childcare Passport Plus Membership ($50)
                        Caregiver add-on ($15)  Name: ___________________________

Payment Options

Amount Enclosed: $__________________

Check                  Check Number: _____________

VISA            MasterCard

Card Number: _________________________________ Expires: _____________
 

Please attach a copy of your current daycare license.

For office use only:

DateRcv: ________  RenDate: ________ Ref#:_________ Amt: _______ TY:

Thank you for your membership.  If you have any questions, please call 218-733-7543.