Participant Name

Home Phone

Mailing Address

City

State & Zip Code

Group Home Name (if applicable

Group Home Owner or Manager

Relationship- check one
Group Home Owner or Manager
Legal Guardian
Parent(s)
Other, please explain __________________________

Cell Phone

Email Address

ANSWERS REQUIRED FOR ALL OF THE FOLLOWING

Yes No - My guardian/parent will volunteer to help out at ARC Rec Center
Yes No - I work at the Kenosha Achievement Center
Yes No - I am currently a member of ARC

ARC Membership dues enclosed:

____ $15.00 Individual Membership

____ $25.00 Family Membership

____ $30.00 Professional Membership

____ $30.00 Group Homes up to 4 Residents, $7.50 each additional resident

Please bring the completed form to your first night at ARC Recreation Center OR mail to:

Dave & Nancy Rupp
2916 50th Street
Kenosha, WI 53144-4270