Membership Application Form
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1
2Southington-Cheshire Community YMCAs
Member #: __________________________________________
Membership Application
First Name:____________________________________ MI: ______ Last Name: _____________________________ Sex: K Male K Female
Informal Name: _____________________
Street: __________________________________________________________________________________ City:_________________________ State: _____ Zip: ______________
Employer:_____________________________________ Member Home Phone: ____________________ Member Work Phone: ____________________ Member Cell Phone: _________________
Emergency Contact: ____________________________________________________ Relationship: ___________________________ Phone Number:________________________________
Date of Birth: ________________________________________________________ E-mail:_______________________________ Preferred Contact Method: (Choose One) K Mail
K E-mail
For Full Family Membership, list family members below:
FIRST NAME
MI
LAST NAME
SEX
DOB
The following is confidential information and is used only as a method to determine if the YMCA is serving a representative portion of our service area. It will not be used or sold for any reason.
ETHNICITY: K African-American
K Asian
K Hispanic
K Native American
K Indian
K Pacific Islander
K Caucasian
K Other
F MILY INCOME: K $0-$25,000
K $25,000-$50,000
K $50,000-$100,000
K $100,000-$150,000
K $150,000+
HOW DID YOU HE R BOUT US? K Current Member
K Newspaper
K Television
K Postcard
K Mail
K Healthcare Provider
K Former Member
K Website
K Brochure
K Drive-by
K Newsletter
K Corporate Sponsor
K Radio
I The undersigned has read the waiver on the reverse side of this document and
voluntarily signs the release and waiver of liability and indemnity agreement, and
OFFICE USE ONLY
further agrees that no oral representations, statements, or inducement apart from the
Membership Type:________________________________ Join Date:______________________________
foregoing written agreement have been made.
I Membership is not transferable and is not refundable.
Billing Method: K Full
K BD
K CCD Renewal Date: ________________________________________
I Membership is subject to forfeiture for violation of rules and regulations of the
Date: ________________________________ Amount: ______________________________________
association. (See program guide for details)
I Credit Card and Bank draft member: 30 day written notice is required to terminate your
Receipt:_______________________________ Date Posted: ___________________________________
membership.
I Financial assistance is available for qualifying individuals and families.
Membership Change: _____________________ to_________________________ __________________
Membership Type
Membership Type
Date
_________________________________________________________
Special Notes: _______________________________________________________________________
Member’s Signature
Date
________________________________________________________________________________
_________________________________________________________
Staff Member: _______________________________________________________________________
Parent’s or Guardian’s Signature
Date
(if participant is legally a minor)
Release and waiver of liability is on the reverse side of this document and must be read by participant or guardian.
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