Membership Application Form printable pdf download

#1 Today’s Date __________________ Expire Date ___________________ Clerk _____________________________

YMCA in Greenfield

451 Main Street

Last Name ________________________________________________________________________

Greenfield, MA 01301

MeMbership AppliCAtion

#2 ( ) New

( ) Gold

( ) silVer

( ) Renewal

( ) Returning

Name ________________________________________________________________ MI ( ) m ( ) f Birth Date _________________ Age ________________

Street ____________________________________________________________________ Phone Number ______________________________________________________

City ______________________________________________________________________ State _______________________________ Zip _____________________________

Corporate Name (employer) _________________________________________________________________________________________________________________

EMAIL _______________________________________________________________________________________________________________________________________________

#4 2nd Adult Name _____________________________________________________________ ( )m ( )f Birth Date ____________ Age __________________

Child _____________________________________________________________________________ ( )m ( )f Birth Date ____________ Age __________________

Parent (s) _____________________________________________________________________Home Number ____________________ Work Number _____________________________

#6 Emergency Contact

_______________________________________ Relation _______________________ Phone _______________________________

(other than parent/spouse)

Membership Type ___________________________________________________________________________________________________________________________________________________

#8 Method of Payment

( ) Bank / CC Draft

( ) 1/2 down, 60 days

( ) paid in full/year

( ) F/A Pmt. Plan

#9 Payment Information Paid Today

#10 Type of Payment :

Gold or Nautilus Add-on

Membership Fee ___________________________________

( ) Visa/MC

Financial %

#22 Member (40%) _________________

( ) Check

#34 Health Deposit _________________

Health Deposit ____________________________________

_____________

( ) Cash

WGL (20/40%)

_________________

MGL (20/40%)

_________________

Locker Fee: $5 BD or $60 YR x ________ lockers

#14 Nautilus (20%)

_________________

Custodial (keys)

_________________

Key deposit $10 x ______ Keys ______

Locker

_________________

Total amount PAID today ____________________

Locker # ______________ M

Monthly draft will be $ ________________

Total balance DUE ______________________________

Serial # __________________________

Starting ___________________________________

Combo #

If ½ down, date balance DUE _________________

_________ - _________ - ___________

#11 Bank Draft Authorization:

I hereby authorize the YMCA in Greenfield to charge my checking / savings / CC account for my monthly YMCA dues of $___________________.

I understand that my dues will be charged on the 13th –15th of the month and will pay for that same month. I also understand that

if my payment is returned to the YMCA by my bank my membership will be terminated if payment is not made to the YMCA by the end

of the month. I agree that I will give written notice to cancel my draft authorization by the last day of the month prior to

the month I wish to stop my membership. The YMCA will give me a 45 day notice of a change of fee structures and I will notify the

YMCA if my account or bank changes. I have provided a cancelled check / savings statement / CC # with my account and routing

numbers.

Authorized signature ___________________________________________________________________________________________________

#12 I assume all responsibility for exercising and participating in the YMCA in Greenfield’s programs in the physical condition I am in.

I agree to notify my physician of my intention to exercise if I have a medical condition, am 40 yrs. of age or older, am physically de-

conditioned or have medical concerns I need to discuss. I also agree to abide by all the rules and policies set forth by the YMCA and to

exemplify the values of caring, honesty, respect, and responsibility while on YMCA property.

Signature: (if under 18, parent or guardian) _________________________________________________________________________

Membership Application Form

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