The Provider Connection
Group Membership Application

 Today's Date:__________________

 Center Name: __________________________________________________

 Address: ______________________________________________________________

 City: _____________________________________ Zip:________________________

 Telephone:______________________ Email address:____________________________

 Age of children cared for: _______________________________________________

Names of Group Members

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Membership Agreement
(to be signed by center director on behalf of all group members)

 We agree to assume responsibility for all materials borrowed on this card and to abide by the  following rules:

• Membership to The Provider Connection is $20.00 per person. Membership is for one year. There will be a $1.00 fee for replacing lost cards.
• Use of The Provider Connection materials & resources after the first year, requires prompt membership renewal. Center is responsible for renewing group memberships on time.
• Verification of member information may be required.
• Only members are allowed to borrow materials. A person may not borrow materials on someone else's card.
• Center agrees to notify The Provider Connection office of change of address or telephone.
• Overdue materials will be subject to fines.
• Most materials may be checked out for two weeks.
• Materials must be returned in original, clean condition.
• Materials not on reserve may be renewed. However, in the interest of equal access to materials, The Provider Connection reserves the right to limit renewals.
• Members must read instruction and use equipment properly and safely.
• Replacement of damaged materials will be the responsibility of the center.
• Full replacement cost of materials will be the responsibility of the center.
• Failure to return materials may result in added fees and possible restriction of membership privileges.
• Center releases The Provider Connection and Palo Alto Community Child Care from any liability for injury to children or adults and damage to property that results from misuse of materials.

 I have read, understood and agreed to the above rules of membership to The Provider  Connection.

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 Center Director Signature                                                      Date

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