Coppell/Valley Ranch Early Childhood PTA
Membership Enrollment Form  
Alumni (Y or N?)* for
members with school aged children who
want to participate in adult activities only
New Member  (Y or N?)
Returning Member (Y or N?)
______________________________________________________________________

Check here if you are interested in being a mentor to a new member
______________________________________________________________________

If you are a new member, how did you hear about us?  

Membership Drive   

Friend      

Newspaper  

Website

Other
Name:
Address, City, Zip:
Phone:
Email:
Birthday:
(year optional)
Spouse Name:
DOB:
Male:

 Female:
Children Name:
Male:

 Female:
Children Name:
 DOB:
Male:
Female:
Children Name:
 DOB:
Male:

 Female:
Children Name:
 DOB:
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CHILDCARE: (9 months and older)
Will you need childcare for the general meetings?
Yes or No?
__________________________________________________________________________________
(Childcare is available through the YMCA. Reservations are required by filling out the nursery form online
at www.cvrecpta.org.  This form is used for planning purposes only).
Please check if you DO NOT want your name/email address used on the web site.    

Please check here if you DO NOT want this information to be published in our directory.  

Please check if you would like a reminder email for our general meetings.                        

*Membership Directories will be available at the October General Membership Meeting
__________________________________________________________________________________
Parental Authorization and Waiver
I, the undersigned parent or guardian of
,
hereby gives approval for said child(ren)to participate in any and all activities of the Coppell/Valley
Ranch Early Childhood PTA.  I assume all risks and hazards incidental to such participation
including, but not limited to, transportation to and from said activities.  I do hereby waive, release,
absolve, indemnify, and agree to hold harmless the Coppell/Valley Ranch Early Childhood PTA,
its officers and members, the locations of meetings (Metropolitan YMCA of Dallas, 601 N Akard,
Dallas, TX 75201) and events, its members and governing body, and any other person or persons
authorized by the Coppell/Valley Ranch Early Childhood PTA in connection with said activities
from any and all claims that could arise out of injury to said child during any meeting, time spent in
a childcare, and field trip or any other activity or function associated with, related to, or sponsored
by the Coppell/Valley Ranch Early Childhood PTA.
Accept Agreement? Y or N
Relationship?
Hold Harmless Agreement
I, the undersigned do hereby declare that I will be participation in various activities of the
Coppell/Valley Ranch Early Childhood PTA.  I assume all risks and hazards incidental including,
but not limited to, transportation to and from said activities, and do hereby waive, release,
absolve, indemnify and agree to hold harmless the Coppell/Valley Ranch Early Childhood PTA,
its officers and members, the locations of meetings (Metropolitan YMCA of Dallas, 601 N Akard,
Dallas, TX 75201) and events, its members and governing body and any other person
authorized by the above from any and all claims arising out of an injury during the meeting, time
spent in childcare, any field trip or any other activity or function associated with, related to, or
authorized by the Coppell/Valley Ranch Early Childhood PTA.
Accept Agreement? Y or N:
 Date:
Children Name:
DOB:
 Allergies/Special Instructions:
This authorization and hold harmless agreement is effective from
August 1, 2008 to September 30, 2009.
_________________________________________________________________________________
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