Membership Application - Ymca Of Northwest North Carolina (Page 2 of 3) in pdf

Payment Authorization

Payment:

Bank Draft Credit Card Draft

Invoice-1 year

Invoice-6 months

Draft Date:

Monthly Draft Amount: _____________________

CHOOSE ONE DRAFT METHOD BELOW and PROVIDE FINANCIAL INFORMATION

BANK DRAFT:

Checking Savings

I authorize the YMCA to draft from my:

Bank Name: _____________________________________________________________________________

Name on Account: _____________________________________________________________________

Routing Transit Number: ____________________

Account Number:

_______________

(Last 4 digits only)

CREDIT/DEBIT CARD: I authorize the YMCA to draft from my:

Visa Master Card

Discover

American Express

Credit Card Number:

_____________ Exp._______________

(Last 4 digits only)

Name on Card: _________________________________________________________________________

Billing Address: ________________________________________________________________________

Member Agreement

1. I understand that this is an on-going membership payment plan.

2. I understand that this payment plan is agreed upon regardless of my facility usage and that the YMCA does not

prorate dues based on facility usage.

3. I understand that it is my responsibility to provide the YMCA with current up-to-date bank or credit card information

throughout the term of my membership.

4. I understand that if I wish to terminate or change membership in any way, I may do so by giving the YMCA a 15-day

written notice with completion of the Membership Cancellation or Change Form. I understand that this means I

may have one final draft after the date I have signed this form.

5. Should any membership deduction not be honored by my bank for any reason, I realize that I am still responsible for

the payment, plus any applicable service charge assessed by the YMCA.

6. I understand that the YMCA is using a third party to assist in the collection of returned checks and bank drafts. If my

check or bank draft is returned for any reason, my account will be debited electronically for the amount of the check

and/or draft plus a processing fee.

7. I understand that the YMCA has 30 days to process my NSF draft.

8. I understand that the YMCA may, at their discretion, cancel my membership based on draft declines and that I am

responsible for the past due balance.

9. I understand that the YMCA Board of Directors may, at their discretion, adjust the monthly rate applicable to my

membership category and that they will give at least 30 days notice of any rate changes.

10. I understand that any YMCA membership may be terminated for the violation of the YMCA Code of Conduct, the Sex

Offender policy, violation of policies and procedures of the YMCA, or any other cause.

This authorization remains in effect until the YMCA has received a 15-day written notification with completion of the

Membership Cancellation Form from me indicating my desire to discontinue my membership.

Member Signature:__________________________________________________________________________________ Date:_________/_________/_________

Office Use Only:

Branch # __________ Membership Type: _______________ Join Date: ____________ Billing: Draft 1 yr 6mo

Prorated Dues/Joining Fee Information:

Pay Method: MC VISA Discover

Check #: ________ Cash: ________

Prorated Dues $_______ Open Doors % _______ Join Fee Amount: $_______ Locker Fees: $_________

Join Fee Discount: Corp. Name _________________ Campaign __________________

Add’l Dependent Fees: _____________

Total Paid: $_________ Receipt # _________ Staff Initials: __________

Our Mission: Helping people reach their God-given potential in spirit, mind, and body.

A United Way Agency

Membership Application - Ymca Of Northwest North Carolina Page 2

Related Articles

Related forms

Related Categories