Carrie On NC, Inc. Christmas Shoppe Application
https://carrieon1.weebly.com/christmas-kindness-store.html
Carrie On NC, Inc. Christmas Kindness Shoppe Pre-Registration
Our store features a unique setup where families have the autonomy to choose their children (and teens!) gifts completely free of charge! We offer multiple stations such as our Want station with action figures, barbies, basketballs, makeup, board games, and all kinds of toys! The need station with hygiene items, school supplies, diapers, and other basic needs. The wear station with coats, hats, scarves, and gloves. The read station with books and art supplies. Our final stations added last year are the stocking station and our wrapping paper station. We also provide batteries to families for toys that need batteries.
COVID Precautions:
Families will be called to schedule their appointment block due to COVID.
Families will be asked to wear a mask throughout the store. If they do not have a mask one can be provided for them.
Due to capacity limites only one parent will be allowed back for the store and we ask that no children be present.
All who enter the building must be screened: temp check, COVID related questions, and must sanitize their hands.
The facility and high touch surfaces will be cleaned the last ten minutes of each hour.
No volunteers are permitted to assist with the store this year, only Carrie On members.
Who's Eligible:
-Families who meet the 200% poverty guidelines (http://aspe.hhs.gov/poverty-guidelines-) -Families with children in crisis or who are displaced (Domestic violence, medical bills, fire or other natural disasters, etc) -Grandparents or other relatives who have permanent or temporary court-ordered custody of children
Legal Guardian
First Name
Last Name
Legal Guardian
First Name
Last Name
Legal Guardian Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Current Living Situation:
(Private home, Relative, Foster, Homeless, Bunked up with other families, etc)
Child Name
First Name
Last Name
Age:
Child Name
First Name
Last Name
Age:
List additional children's names & ages below:
please note developmental delays that affect choices in toys/etc.
Please explain the families situation that makes them eligible (Medicaid, FNS, and Work First eligibility make families automatically eligible for our store. If families do not wish to disclose this information please explain why you feel the family would benefit from the store and we can make a decision if that information is enough for a determination).Please note that if you have participated in our shoppe for 3+ consecutive years your application will be based on board decision :
Families Monthly Income:
(income, child support, Work First, etc.)
Estimated Monthly Bills:
(rent, utilities, childcare, etc.)
Person Completing Form:
First Name
Last Name
Contact Number:
-
Area Code
Phone Number
Email Address:
example@example.com
Provider Consent
If you are a provider providing this referral with a parent please complete the bottom portion of this form. I agree that I completed this application with the parent and that the parent has consented to their information being shared at their own free will.
Provider Signature
Consent for Services & Liability Form For Store
In consideration of the risk of injury while participating in the Christmas Kindness Store 2019 (the "Activity") offered by Carrie On NC, Inc., and consideration for liability and consent to services in the Activity, I Hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, and do hereby release and forever discharge Carrie On NC, Inc. located at P.O Box 14973, New Bern, NC 28561, their affiliates to include Township 6 Fire Dept., managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, and all others involved in Christmas Kindness Store 2019 for any physical or psychological injury, including, but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned Activity, including traveling to and from an event related to this Activity. I am voluntarily participating in the aforementioned activity and participating in the activity entirely at my own risk. I understand that the Christmas Kindness Store 2019 in itself should not carry these certain risks,however, I am aware of all activities could carry potential risks therefore I acknowledge the risks associated with this activity including, but not limited to, risks associated with traveling to and from the activity, physical, psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and death. I understand that these injuries may arise from my own or others’ negligence, conditions related to travel, or the condition of the activity. Nonetheless, I assume all related risks, both known and unknown, of my participation in this activity. I agree to indemnify and hold harmless “Carrie On NC, Inc.” and all of the above named and unnamed against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If Carrie On NC, Inc. incurs any of these types of expenses, I agree to reimburse Carrie On NC, Inc. I acknowledge that Carrie On NC, Inc., their directors, officers, volunteers, representatives, members, and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Carrie On NC, Inc. I grant to Carrie On NC, Inc. its representatives, volunteers, and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize Carrie On NC, Inc., its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Carrie On NC, Inc. & named businesses may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content without identifying names or information. I acknowledge that I have carefully read this “waiver and consent for services” and fully understand that it is a release of liability. I understand and expressly release and discharge Carrie On NC, Inc.and all of its affiliates, members, managers, agents, attorneys, staff, heirs, volunteers, representatives, community resource locations, predecessors, successors, and assigns from all claims or causes of actions and I agree to voluntarily give up or waive any right that I otherwise have to bring legal action against Carrie On NC, Inc. for personal injury or property damage. To the extent that the statute or case law does not prohibit releases of negligence this release also releases negligence on the part of Carrie On NC, Inc. all of its affiliates, members, managers, agents, attorneys, staff, heirs, volunteers, representatives, community resource locations, predecessors, successors, and assigns. In the event that I should require medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. In the event that any damage to equipment or facilities occurs as a result of my or my families willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness. This Agreement was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between the two parties of equal bargaining strength. Both the Participant and Carrie On NC, Inc. agree that this Agreement is clear and unambiguous as to its terms, and that no other evidence will be used or admitted to alter or explain the terms of this Agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into. In the event that any provision contained within this Release of Liability shall be deemed to be sever-able or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect, so long as the clause severed does not affect the intent of the parties. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited. I, the undersigned participant, affirm that I am of the age of 18 years or older, and that I am freely signing this agreement I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is a release of liability and a contract that I am signing it of my own free will. I understand that if at any time I wish to revoke my request for assistance I am able to do so.
Parent Signature:
Submit
Should be Empty: