Discovery Center Contribution Form

Douthat State Park Environmental Education Group
Douthat State Park * Route 1, Box 212 * Millboro, VA 24460
Phone: (540) 862-8100 * Fax: (540) 862-8104
Email: douthatspeed@yahoo.com
Website: www.douthatspeed.org

Name:_____________________________________________________________________

Organization or Business:_________________________________________________

Mailing Address:__________________________________________________________

Home Phone:________________________ Work Phone:___________________________

Email Address:____________________________________________________________

Signature:________________________________________________________________

Yes! I want to support the future Douthat State Park Discovery Center.

     Sign me up at the following level:

$50 or above
$100 or above
$500 or above
Other
     Enclosed is my check in the amount of _____________.

Make checks payable to:
Douthat S.P.E.ED. Group
Write in the memo or note section:
Douthat Discovery Center
Mail checks to:
Treasurer
Douthat S.P.E.ED. Group
Douthat State Park
Route 1, Box 212
Millboro,Virginia 24460



*S.P.E.ED. Use Only*
Date Discovery Center Contribution Received and Amount Paid:_______________