CECA Membership Enrollment Form

Membership Enrollment Form
Please provide your personal details.
* Required
Membership Type *
Choose
New Member
Renewing Member
Alumni Member
First Name *
Your answer
Last Name *
Your answer
Email *
This address is where we will send all of our CECA communications.
Your answer
Preferred Phone Number
Please format as 123-456-7890.
Your answer
Address
Your answer
Birthday
Optional. We like to celebrate our member birthdays in the newsletter!
MM
/
DD
Do you want your information (i.e. birthdays and birth announcements) to be published in our newsletter? *
Family
We use this information to establish playgroups and to determine the amount of kids we are serving.
Spouseʼs Name
Your answer
Child 1
list children ages 0-6yrs
Child 1 Name
Your answer
Child 1 Birthday
MM
/
DD
/
YYYY
Child 1 Gender
Choose
Male
Female
Prefer not to answer
Child 2
list children ages 0-6yrs
Child 2 Name
Your answer
Child 2 Birthday
MM
/
DD
/
YYYY
Child 2 Gender
Choose
Male
Female
Prefer not to answer
Child 3
list children ages 0-6yrs
Child 3 Name
Your answer
Child 3 Birthday
MM
/
DD
/
YYYY
Child 3 Gender
Choose
Male
Female
Prefer not to answer
Child 4
list children ages 0-6yrs
Child 4 Name
Your answer
Child 4 Birthday
MM
/
DD
/
YYYY
Child 4 Gender
Choose
Male
Female
Prefer not to answer
What is your main purpose for joining the Coppell Early Childhood Association?
Please choose all that apply:
Liability Release:
I understand that my child(ren) must be accompanied by a parent, guardian, or responsible adult at all Coppell Early Childhood Association functions and that the parent, guardian, or responsible adult is in charge of that child’s behavior and safety. In case of an emergency or accident, neither Coppell Early Childhood Association nor its members shall be responsible. By signing this form, I authorize the use of photos that myself or any member of my family may appear in at a Coppell Early Childhood Association event for use on the Coppell Early Childhood Association website and Coppell Early Childhood Association publications.
Parent/Caregiver's Signature: *
Your answer
Date: *
MM
/
DD
/
YYYY
Membership Dues
After you click Submit, please be sure to pay your dues via PayPal.

• $30 for Full Year Membership (member year runs August-July)
• $20 for Partial Year Membership (membership beginning after January 1st)
• $10 for Alumni Membership (you have graduated out of CECA because ALL of your children are in Kindergarten or older).
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