Membership Inquiry Form

ALL PARTICIPANTS NEW AND OLD, MUST BE REGISTERED AND CONFIRMED, TO PARTICIPATE IN ANY OF CARRIE’S KIDS PROGRAMS AND ACTIVITIES.  SPOTS ARE LIMITED, SO SIGN UP NOW!

Please complete this Membership Inquiry Form and we will get back to you when a space opens up.


(if you don't have a home phone, please enter cell again)


(if you don't have a cell, please enter home phone again)

xx/xx/xxxx

Extracurricular activities:

Please mark which events/clubs the participant would be interested in:

Allergies?

Is an Epi-pen required for any allergy?

Field Trip Transportation and Supervision

I agree to permit the child named above to participate in walking trips, field trips or other activities sponsored by Carrie’s Kids, Inc. This permission is given with the understanding that transportation, if needed, will be provided by private vehicles driven by Carrie’s Kids, Inc. staff volunteers, and/or public transportation to include taxis. I also understand that the children will be under Carrie’s Kids, Inc. supervision throughout the duration of any field trip.

I accept:

Safety

Knowing there is a certain amount of risk involved in even the simplest of children’s games, sports and activities, I give my permission for my child to participate in Club activities and programs. I accept responsibility in the unlikely event that an accident might take place. I hereby certify that I carry health and/or accident insurance for my child and that I am solely responsible for the cost of health care for my child, even as a result of my child’s participation in Club programs or activities.

I accept:

EMERGENCY CONTACT INFORMATION (Must be a parent or guardian if under 18)

If primary Emergency Contact is unavailable, please provide a secondary contact:




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Donate by mail

1223 South 12th St Suite #3
Bismarck, ND 58504

Donate Site Address

(9am - 4pm M-F)

Our Donation site is the
Superior Silk Screen building