Membership Application Form
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1Membership Application
____Scholarship
___Student
___1Adult
___2Adult
___Single Parent Family
___Household
Daxko Unit ID Number:____________________
PRIMARY ADULT CONTACT (Must be an adult)
FIRST NAME:
LAST NAME:
HOME ADDRESS
CITY
STATE
ZIP
PHONE
EMAIL
DOB ____/____/________
M / F
RACE (collected only for the purpose of responding to funding)
___American Indian
___Asian
___African American
___Hispanic or Latino
___White
___Other
ADDITIONAL FAMILY MEMBERS
RACE
ND
2
ADULT NAME
DOB ______/______/_______
M / F
CHILD #1
DOB ______/______/_______
M / F
CHILD #2
DOB ______/______/_______
M / F
CHILD #3
DOB ______/______/_______
M / F
CHILD #4
DOB ______/______/_______
M / F
CHILD #5
DOB ______/______/_______
M / F
EMERGENCY CONTACT
PHONE
Relationship
MEMBERSHP PAYMENT OPTIONS - Written Notice with Signature must be received prior to the lst day
th
of the month to affect a change on an impending draft which occurs on the 14
of each month.
Monthly Payments - I authorize the following bank or credit card company to honor drafts drawn by the YMCA
on my account for my membership monthly fees. Should my bank not honor any draft, I understand that the YMCA
has the right to resubmit the draft including a $25 service charge fee. Said payment and service charge will be
submitted as an additional draft at anytime following the notice of dishonoring the original draft. Additional rules
apply – please refer to our member handbook. I agree to abide by the rules and policies of the YMCA, including
changes approved by its governing bodies in accordance with its Charter and By-Laws.
___PLEASE DRAFT MY MEMBERSHIP FEES FROM MY CHECK/SAVINGS ACCOUNT.
_____ (Attach voided check or deposit slip)
___PLEASE DRAFT MY MEMBERSHIP FEES FROM MY CREDIT CARD.
__VISA __ MASTERCARD __DISCOVER
Last 4 digits: ___
___ ___ ___
Annual Payments - Annual payments may be made by cash, check or credit card (
Visa, Master Card or Discover).
All new memberships are required to pay an administrative Join Fee. The YMCA reserves the right to change membership
fees with thirty (30) days written notice to members.
I understand a $25 fee will be charged on all returned/declined drafts. I also understand written notice must be
received before the lst day of the month to cancel/change an impending draft.
Member Signature
Date
Staff Name (Please Print)
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