Ymca Of Memphis & The Mid-South Membership Application
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1
2YMCA OF MEMPHIS & THE MID-SOUTH
MEMbERSHIP APPLICATION
PLEASE PRINT
___/____/____
Name:
Sex: q M q F
Birthdate:
First
M
Last
_______________________________________
Casual Name:
Phone:
____________________________________________
_______________________
______
________________
Address:
City:
State:
Zip:
*
*
*
*
African-American
Caucasian
Multiracial
Other
*
*
*
_______________
Marital Status: q Single q Married
Ethnicity:
Asian
Hispanic
Native American
q
By providing your email address to the YMCA, you will have access to YMCA online services and will receive YMCA e-newsletters.
______________________________________________________
___________________________________
Email Address:
Cell Phone:
_________________________________________________________
__________________________________
Employer:
Work Phone:
Emergency Contact:
Phone: ____________________________________
Medical Alert Information:
SPOUSE INFORMATION*
___/____/____
Name:
Sex: q M q F
Birthdate:
First
M
Last
______________________________
Casual Name:
Phone:
Email:
*
*
*
*
African-American
Caucasian
Multiracial
Other
______________________________________
*
*
*
_______________
Employer:
Ethnicity:
Asian
Hispanic
Native American
IRS DEPENDENTS*
Family Member Names
Relation
Sex
Birthdate
Ethnicity
* It is the policy of the YMCA of Memphis & the Mid-South that all family members listed on a YMCA family membership must be IRS
dependents of the billable member listed above. Proof may be required.
jOININg FEE
HOw DID YOU HEAR
OFFICE USE ONLY
AbOUT THE YMCA?
*
Pay in full today
Date
/
/
Branch
*
*
TV
Pay a minimum of one-third today and the
balance will be added to your first two drafts.
*
Radio
Open Doors Income Level
*
Senior Discount
*
*
*
Newspaper or Magazine
$40,000-$49,999
<$20,000
*
Corporate Discount
*
*
*
Mailing/Postcard
$50,000-$59,999
$20,000- $29,999
*
*
*
>
Online
$60,000
$30,000-$39,999
*
YMCA Website
*
Staff
Employer
OPTIONAL FEES
(At Select Branches)
*
Member Referral
*
Locker #
Bankdraft
Mbr Type
Mbr #
*
Drive By
*
Size
Annual
*
Doctor
Next Bill Date:
Corporate:
*
6 Month
*
*
*
*
*
I was a previous member
Epay
6 month
Annual
Monthly
*
Other
Receipt #
Amount Paid
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Parent category: Business