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Membership Form

Producer Name
First Last
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer
Supervisor
Supervisor Contact
Name of nearest living relative (not living with you)
Address of relative
Street Address Address Line 2 City State ZIP Code
References
Please provide two references
Reference #1 Name
Reference #1 Phone
Reference #1 Address
Street Address Address Line 2 City State ZIP Code
Reference #2 Name
Reference #2 Phone
Reference #2 Address
Street Address Address Line 2 City State ZIP Code
Consent*
I will be completely and wholly responsible for the care, safekeeping, and custody of all equipment used in and out of the facility. In the event of loss, theft, damage, or irresponsible use of the equipment, I will be held responsible for the total cost of its' repair or replacement as determined by WFMC Staff. Failure to return equipment on time or failure to take proper care of said equipment while in my possession or the possession of my child will result in forfeiture of my right to use the equipment.
I have read and understand WMFC's Operating Policies and Procedures and agree to abide by them.

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