|  With Open Arms, Inc.
Offering a hand up, not a hand out
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With Open Arms, Inc.
Samantha’s Open Arms
Membership Application Current membership is $25 a month
I am (check one):
New Member__
Renewing Member__
Please complete all sections
Child’s name:_______________________________________________ sex _____ Age ____ Date of birth _________
Street Address:_____________________________________________
City: _______________ State: ______ Zip: ____________
Mailing Address: __________________________________________
Email: ___________________________________________________
Home phone: _______________________________________
School: ___________________________________________________
Grade: ______________________________________________
________________________________________________________________________________________________________________________
Emergency Contacts:
Father/guardian’s Name: ___________________________________ Work Phone: ___________________Home phone: ________________
Mother/guardian’s Name: ___________________________________ Work Phone: _____________________ Home Phone: _____________
________________________________________________________________________________________________________________________
Alternate Emergency Contact: if parent or guardian cannot be reached ___________________________
Phone: ___________________________________ Relationship to child: ______________________________________________
Medical: Does child have any medical problems? __ YES __NO Any Allergies? __YES __NO
If yes, please explain (use other side if needed) __________________________________________________________
________________________________________________________________________________________________________________________
Doctor’s Name: _________________________________________ Phone: ________________________________________________
Authorized individuals who may pick up this member from our program site:
1. ___________________________________________________
2. ____________________________________________________
3. ____________________________________________________
4. ____________________________________________________
I hereby approve of my son’s/daughter’s application for membership in Samantha’s Open Arms and give my consent to his/her being given physical examination, emergency examination or treatment by a physician or hospital in case of an accident. I further agree to his/her taking part in various athletic, cultural, and social activities, and will not hold the members of the Board, staff, the news media, permission to publish/use photographs or videotape footage of my son/daughter for any purpose relating to Samantha’s Open Arms and any news media of responsibility from the use of such photographs or footage.
Parent/guardian’s Signature: _________________________________ Date: ___________________
Please notify the office of any changes to your child’s information.
Samantha’s Open Arms does offer grants for this program. If you are interested in applying for a grant, fill out this section. You will be notified within 72 hours whether your grant was accepted or denied.
INCOME LEVEL: Include ALL household income
$0 - $15,000
$15,001 - $30,000
$30,001 - $45,000
$45,001 - $60,000
$60,001 - $75,000
$75,001 - $100,000
$100,001 - +
Number of dependents residing in household
1
2
3
4
4
6 +
OFFICE USE ONLY
Membership Number: __________________________________
Scholarship Amount: $ ________________________
One time Award
Monthly Award Director Signature: ______________________________
Amount Paid: $ ____________________
Cash Staff signature: ____________________________
Check
Receipt Number: ___________________________
DEMORGRAPHIC INFORMATION: This information is required for grant reports on funding we receive that keeps your membership fees affordable for everyone. This information is kept strictly confidential and anonymous. The information is only used (without your child’s name) for grant reporting purposes that supports current programs that we are able to offer your child. We appreciate your assistance.
Circle one:
Race: African-American Asian-Indian Hispanic Latino Native American Alaska Native
Bi/Multi Racial Caucasian
Circle one:
INCOME LEVEL: (include ALL household income)
$O - $15,000 $15,001- $30,000 $30,001 - $45,000 $45,001 - $60,000
$60,001 - $75,000 $75,001 - $100,000 $100,001 +
Check one: Number of Dependants residing in household: __1 __2 __3 __4 __5 __6 more_______
Check one: Household: __ Both parents __ Mother only __Father only __ Grandparents __ Other
Fill In: Child’s age: ___ Is your child eligible for the school year Free Lunch Program? Y N
Check One:
Special needs includes participation with physical, developmental, cognitive, emotional, behavioral, or medical limitations who require a level of care over and above the norm.
___Physical __ Developmental __Cognitive __Emotional __Behavioral __ Medical __ None
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