Please print legibly                                                                                         Date:                                           
                                   
Name:                                                                              Job Position or Parent:                                      

Center/Agency/School Name:                                                                                                                    

Number of Staff            phone:                                 E-mail:                                                                      

Address (specify work if job related):                                                                                                          

City:                                Zip:                         

Number of children in age group served:  ____infant/toddler ____ pre-school _____school age

1.  Organization type: (please check all that apply):
___ non-profit child care center ___ family child care  ___ Number of subsidized slots in center ___ for-profit child care center  ___ at home family    ___  private school      ___ home-school           ___ public school      ___ non-profit organization  ___ faith-based group       

2.   Approximately how much do you spend as an individual or center/organization each year on supplies for children?    ___$0-25     ___$25.01-100     ___$100.01-250     ___$250.01-500          $500.01-750     ___$750.01+ 

3.   What would you spend the money you saved for?                                                                           

4.  Have you participated in a “Play is Learning” Workshop? no ____  yes ____  date __________            

I agree to abide by the following guidelines:  Materials are to be used for the specific purpose of working directly with children in educational and creative learning activities.  I agree that in order to continue to use the center on the next visit I will return a finished product or a picture of the product(s) or materials in use.  These materials may not be used by individuals or organizations for disbursement without a collaborative agreement.   

                                                                                                                                                                       
                                                Print name                                                                                       Signature

Membership Categories *                                                         
* Organization agrees to use materials directly with children
   
     Members                            Membership Processing Fee * *               Poundage
            1                                                     $25                                                  30 lbs
            2-3                                                  $50                                                  65 lbs
            4-7                                                  $100                                                140 lbs
            8-13                                                $150                                                200 lbs
            14-24                                              $200                                                300 lbs
            25+                                                 $300                                                500 lbs        

**Membership processing fee includes shopping trips with above stated poundage:
some items have number of package limits; not all items are calculated equally per pound;
additional pounds may be purchased for $1per lb.

Continuing Education Workshop Fee:    $5.00  per person      

How did you hear about the ReThink and ReUse Center? 
ReThink and ReUse Center Presentation   ___ meeting  ___ The Children’s Trust   ____ CDS ____         MD/M-ELC   ___ website  ___  work ___   friend ___   other __________________

ReThink and ReUse Center, Inc

Hold Harmless Agreement & Disclaimer of Warranties
Member understands and agrees that the ReThink and ReUse Center, Inc. provides material “AS IS” and that any and all warranties, express or implied, including, without limitation, any such warranties of merchantabiltity or fitness, are hereby excluded and disclaimed.  Moreover, Member agrees that such disclaimer and exclusion applies to all materials provided to Member regardless of any oral statemEnts made to Member and regardless of any course of dealing with Member.  Notwithstanding anything else to the contrary contained herein, ReThink and ReUse Center, Inc. is and shall not be liable to Member or any other person for consequential, special or punitive damages of any kind whatever.  MEMBER FURTHER AGREES TO INDEMNIFY AND HOLD HARMLESS THE RE THINK AND REUSE CENTER FOR ANY INJUSRIES OR DAMAGES ARISING FROM THEIR USE OF THE WAREHOUSE LOCATED AT 4548 SW 75TH AVENUE, MAIMI, FLORIDA INCLUDING NOT LIMITED TO THEIR PERSON AND THEIR VEHICLE.

AUTHORIZATION FOR PHOTOGRAGRAPHY
I authorize the ReThink and ReUse Center and The Children’s Trust to photograph my child or guardian and/or my family and to use the photographs, videos, or any other media for educational, research, documentary and public relations purposes. I also waive any rights to present and future use and/or compensation for myself, children or wards.  Any and all recordings named above are the property of the ReThink and ReUse Center or The Children’s Trust.

I give my permission for this information to be submitted to The Children's Trust for program monitoring and evaluation purposes.

Center Name:  ______________________________________________________________________
Name  (please print)                        Signature                                            E-Mail Address