Membership

Please fill out this form to start your process. Our Membership Coordinator will contact you about your status and next steps. A limited number of subsidized spaces are available on a first-come, first-serve basis.

Parent's Name

First Name

Last Name

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Child(ren)'s Name(s)

Child(ren)'s Age(s)

Allergies

If yes, does your caregiver carry an EpiPen?

Yes

No

N/A

Emergency Contact

Name and Phone Number

Caregivers Name

This is the person who will attend Break for Play with your child(ren) on a regular basis

Caregivers Phone

(###)

###

####

Is the caregiver CPR certified?

This is for our information, and is not required for participation in Break for Play

Yes

No

How did you hear about us?

Membership

Break For Play Cooperative Play Group

Info

Program