The Provider Connection
Individual Membership Application

 Today's Date:__________________

 Name: __________________________________________________

 Address: ______________________________________________________________

 City: _____________________________________ Zip:________________________

 Telephone:______________________ Email address:____________________________

 Child Care Program: _____________________________________________________

 Age of children you care for: _______________________________________________

Membership Agreement

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

• Membership to The Provider Connection is $25.00. 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. Member is responsible for renewing membership 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.
• Member 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 member.
• Full replacement cost of materials will be the responsibility of the member.
• Failure to return materials may result in added fees and possible restriction of membership privileges.
• Member 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.

_____________________________________    _____________________________
 Member Signature                                                      Date

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