Membership Application - Ymca Of Northwest North Carolina
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3YMCA of Northwest North Carolina
Membership Application
List responsible payee 1
st
Date: _______________________
Branch: _________________________________ Membership Card #_______________________________________________________
Membership Type:
: Teen Young Adult Adult Adult w/ Dep Household Senior Silver Sneaker Metro Triad
CIRCLE
First Name: ______________________________________MI____________Last______________________________________________________ DOB________/_______/________
Mailing Address: _______________________________________________________________________________________________________________________Gender: M
F
Apt #
City: _____________________________________________________________________________ State: _________________________________ Zip:______________________________
Primary Phone: ______________________________________________________________ Email: ______________________________________________________________________
Emergency Contact: ________________________________________________________ Emergency Phone: _______________________________________________________
Wells Fargo Express Wellness Center Only:
Work Phone Number: _________________
Employer: ______________________________________________________________
Employee ID # ____________________ A1 # _________________________
Ethnicity:
African American
Native American
Alaskan Native
Asian/Pacific Islander
Caucasian
(Please circle one)
Hispanic
Prefer not to answer
Other
How did you hear about the YMCA? (Please circle one)
Radio
Television
Billboard
Drive By/live in area
Former member
YMCA website
Direct Mail
E-mail
Yellow Pages
Newspaper
Medical Referral
Friend/Family
Other Website
Facebook
Member (Name)_________________________
Insurance
Magazine
Place of Employment
Other social media
Office Use: Member Referral Date: __________
Applied Date : ____________
Staff Initial ______
Second Adult
Membership Card #__________________________
First Name: ___________________________MI______Last______________________________DOB_____/____/____
Primary Phone: ____________________________________Email:___________________________________________
Gender: M
F
Ethnicity:
African American
Native American
Alaskan Native
Asian/Pacific Islander
(Please circle one)
Caucasian
Hispanic
Prefer not to answer
Other
Other Adults or Dependents (under 23)
Adult ______ Dependent ______
Membership Card #__________________________
First Name: ___________________________MI______Last______________________________DOB_______/______/______
Primary Phone: ____________________________________Email:___________________________________________
Gender: M
F
Ethnicity:
African American
Native American
Alaskan Native
Asian/Pacific Islander
(Please circle one)
Caucasian
Hispanic
Prefer not to answer
Other
Other Adults or Dependents (under 23)
Adult ______ Dependent ______
Membership Card #__________________________
First Name: ___________________________MI______Last______________________________DOB_______/______/______
Primary Phone: ____________________________________Email:___________________________________________
Gender: M
F
Ethnicity:
African American
Native American
Alaskan Native
Asian/Pacific Islander
(Please circle one)
Caucasian
Hispanic
Prefer not to answer
Other
Other Adults or Dependents (under 23)
Adult ______ Dependent ______
Membership Card #__________________________
First Name: ___________________________MI______Last______________________________DOB_______/______/______
Primary Phone: ____________________________________Email:___________________________________________
Gender: M
F
Ethnicity:
African American
Native American
Alaskan Native
Asian/Pacific Islander
(Please circle one)
Caucasian
Hispanic
Prefer not to answer
Other
Our Mission: Helping people reach their God-given potential in spirit, mind, and body.
A United Way Agency
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