Membership Application Form s6

MUMFERD’S SAFETY TALES RESIDENCY APPLICATION APPLICANT INFORMATION Name of organization: Title/relationship to organization: Point of contact: Phone:

Organization address: City: State: ZIP Code: County: Number of classes: (if relevant) Age of children:

TELL US ABOUT YOUR CHILDREN: How would Mumferd’s Safety Tales be beneficial to the children at your facility?

Were you invited to apply for a Mumferd’s residency?

TELL US ABOUT YOUR GROUP: How long has your group been in existence?:

Mission of your organization: Are you a: (circle all relevant)

501c3 Non-profit organization

School daycare

headstart program

faith-based organization

program serving children with special needs: (please clarify:)______

Other:______

[ ] I verify all information is accurate to Print name: Date: the best of my knowledge Signature: Date: