EmailMe Form - Friends of The Resource Place Membership Agreement

Contact Information

Please provide your personal contact information.

Name *

First Last

Name of Program

Applies to all child care center and organizational memberships.

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home/Cell Phone *

### - ### - ####

Work Phone

### - ### - ####

Email *

Date of Birth *

MM / DD / YYYY

Driver's License # *

Are you a NEW or RENEWING member?

New

Renewing

Checkbox

Child Care Professional - $12

Individual - $25

Partner / Intern

** Membership is free to legally operating Child Care Centers and Family Child Care Home Operators. You must provide a copy of your current license or Exemption Letter to receive a free membership.

Persons Authorized to Use Membership

Applies to Child Care Centers, Family Child Care Homes and Organizations - Maximum of 3 staff.

Name

First Last

Name

First Last

Name

First Last

Membership Terms:

All Resource Place patrons and visitors are required to sign in and out when visiting the facility. You are responsible for any and all Resource Place materials (including toys, videos, books, cassettes, computer disks, or modules) borrowed on your membership, with or without consent. Card holder will be billed for damaged or lost items. Collection will be sought to replace items in the event of failure to adhere to lending policies. Return Resource Place materials on time and in good condition to a representative of THe Resource Place. REPORT LOSS OF MEMBERSHIP CARD OR CHANGE OF NAME OR ADDRESS IMMEDIATELY. You membership may be revoked by The Resource Place at any time.

Acceptance of Membership Terms:

Please place your name and the current date in the fields below if you accept the Membership Terms stated above.

Signature

First Last

Date

MM / DD / YYYY