DAY LOCALS APPLICATION - SECTION 5

SIGN & SUBMIT

A “RESPONSIBLE PARTY” INDICATES THE INDIVIDUAL(S) WHO MAY BE CONTACT IN THE EVENT OF EMERGENCY OR OTHER CONCERN AS IT PERTAINS TO YOUR PARTICIPATION IN THE SOUTHWIND FIELDS CITY LOCALS PROGRAM. THIS PERSON MAY BE A PARENT, ADULT SIBLING, INVOLVED FAMILY MEMBER, LEGAL GUARDIAN, OR OTHER NAMED, INVOLVED INDIVIDUAL. THIS PERSON MAY BE GIVEN INFORMATION REGARDING YOUR PARTICIPATION IN THE PROGRAM AS DEEMED APPROPRIATE FOR YOUR SAFETY AND INDEPENDENCE.

IF YOU DO NOT WISH FOR ANYONE TO BE CONTACTED REGARDING YOUR PARTICIPATION IN THE PROGRAM, PLEAE LEAVE THAT SECTION BLANK.

RESPONSIBLE PARTY

First Name

Last Name

Relationship

(i.e. mother, father, sister, friend, guardian, etc.)

Responsible Party Phone Number

(###)

###

####

Responsible Party E=Mail Address

RESPONSIBLE PARTY No. 2

First Name

Last Name

Relationship

Responsible Party Phone Number

(###)

###

####

Responsible Party E-Mail Address

Should you be accepted into the program, membership dues are paid monthly via online invoice. Please provide the email address you wish these invoices to be sent to. You will not be invoiced until services have begun, pending acceptance into Southwind Fields programming.

PLEASE READ THIS SECTION VERY CAREFULLY AND ASK QUESTIONS IF YOU DO NOT UNDERSTAND SOMETHING. WE WILL BE HAPPY TO ASSIST YOU WITH UNDERSTANDING. YOU MAY ALSO ASK ANYONE WHOM YOU TRUST TO HELP YOU UNDERSTAND WHAT YOU ARE READING AND MAY HAVE THIS DOCUMENT READ TO YOU BY A SOUTHWIND FIELDS STAFF. BY SIGNING THIS DOCUMENT, YOU ARE AGREEING THAT YOU FULLY UNDERSTAND EACH AREA OF THE APPLICATION AND HAVE ANSWERED ALL QUESTIONS TRUTHFULLY AND TO THE BEST OF YOUR KNOWLEDGE. I certify that I have answered all areas of the above application to the best of my ability and knowledge. I certify that I have answered all questions truthfully and have not made any effort to deceive a member of the Southwind Fields staff or any representative of the organization. I understand that any discrepancy or failure to complete any section of this application may my being declined for admittance to the Southwind Fields Day Local (Local Society) program. I also understand that failure to provide necessary documentation as outlined below or pay required program fees may result in my dismissal from the Southwind Fields Day Local (Local Society) program. By entering my name below, I understand that it will be recognized as my legal signature.

Today's Date

YYYY

Signature of person assisting in submission of application, if any

Today's Date

YYYY