Family Membership Application

(Memberships are subsidized through Carter's Crew, Inc. 501(c)(3))

Family must have a child(ren) that has an official diagnosis/special need
Annual household income will be taken into consideration during qualification process and may be subject to review through various documentation requests.

I am applying for a family membership at Carter’s Play Place and ensure all information provided on this application is accurate. All members must ensure safety procedures are observed while at Carter’s Play Place. It is the parent / guardian’s responsibility to supervise his/her child(ren) while at Carter’s Play Place. This gym membership shall remain valid for a period of three hundred and sixty five (365) days and reviewed on an annual basis for renewal.

Date *

Date

Submission Date

YYYY

Parent's/Legal Guardian's Full Name

First Name

Last Name

Home Address *

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Email Address *

Total Annual Household Income *

Number of Children *

Number of children in your household under legal guardianship

Child 1 Name *

Child 1 Name

First Name

Last Name

Child 1 Birth Date *

Child 1 Birth Date

YYYY

Chlld 2 Name

First Name

Last Name

Child 2 Birth Date

YYYY

Child 3 Name

First Name

Last Name

Child 3 Birth Date

YYYY

Child 4 Name

First Name

Last Name

Child 4 Birth Date

YYYY

Child 5 Name

First Name

Last Name

Child 5 Birth Date

YYYY

Emergency Contact Name *

Emergency Contact Name

First Name

Last Name

Emergency Contact Relationship *

Emergency Contact Phone *

Emergency Contact Phone

(###)

###

####

Child Diagnosis/Diagnoses *

Name and/or Brief Description

Comments