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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
Parent's/Legal Guardian's Full Name
Parent's/Legal Guardian's Full Name
Home Address *
Home Address
Home Phone *
Home Phone
Mobile Phone
Mobile Phone
$
Number of children in your household under legal guardianship
Child 1 Name *
Child 1 Name
Child 1 Birth Date *
Child 1 Birth Date
Chlld 2 Name
Chlld 2 Name
Child 2 Birth Date
Child 2 Birth Date
Child 3 Name
Child 3 Name
Child 3 Birth Date
Child 3 Birth Date
Child 4 Name
Child 4 Name
Child 4 Birth Date
Child 4 Birth Date
Child 5 Name
Child 5 Name
Child 5 Birth Date
Child 5 Birth Date
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
Name and/or Brief Description