Ymca Of Memphis & The Mid-South Membership Application (Page 2 of 2) in pdf

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AUTHORITY TO DRAw ACH DEbITS OR DRAFTS FOR MEMbERSHIP PAYMENTS

Savings

Checking

Credit/Debit

Name on Bank/Credit Card Account

Joining Fee Draft

1st mth

2nd mth

N/A

Membership

Optional Fee 1

Billing Address (On Account)

Optional Fee 2

Total Monthly Draft

PLEASE NOTE: 30 days advance notice from draft date in person or by a registered letter for

cancellation.

Depositor’s Account Number

CC ending in

Exp

Bank Route & Transit Number

q V

q MC

q AMEX

q Disc

I have given authority to my financial institution to honor preauthorized checks/drafts drawn by the YMCA on the above account for membership payments. I understand

that the sending of a preauthorized check/draft to my financial instituion as a payment becomes due shall constitute valid notice of such payment due on this member-

ship. When the financial institution honors the check/draft by charging my account, such check/draft shall constitute my receipt for the payment. Should any preautho-

rized check/draft not be honored by said financial institution, then it is understood that the payment is to be made by me in the amount of said payment plus a service

charge. Membership fees subject to change with a 30 day written notice to member.

Signature of bank Depositor/Account Holder:

wAIVER

The YMCA of Memphis & the Mid-South will not assume responsibility for any injury incurred while participating in any athletic event, sports program,

or any physically related activity. Certain risks are inherent during participation in these events.

The YMCA of Memphis & the Mid-South will not be liable for lost or stolen items while members and/or program participants are using YMCA facilities

or are not on the YMCA premises. I, the undersigned for myself, my heirs and assigns, do hereby release the YMCA of Memphis & the

Mid-South and its branches, employees and agents from any and all claims for injury, death, loss or damage I may suffer as a results of my participation.

I assume full responsibility for removing myself from any media opportunities that I do not wish to participate in. I hereby grant to YMCA the unrestrict-

ed right to use and publish photographic images of me, or in which I may be included, for marketing materials, YMCA websites or YMCA social networks,

editorial trade advertising, and any other lawful purpose related to the YMCA.

I understand and agree that bank/credit card draft and a’la carte programs do not have an expiration date. To cancel a program or my membership, I

must complete a cancellation form in person or send a registered letter, giving 30 days notice prior to my bank draft and return my permanent member-

ship cards. (Cancellation forms may be obtained at the YMCA branch).

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

primary member listed on reverse side. Proof may be required.

I understand that joining fees, prepaid semi-annual and annual memberships are non-refundable.

I understand that if I terminate my membership, I have 60 days to rejoin without paying a joining fee, and that all past due balances must be paid before

joining or re-joining the YMCA.

SIgNATURE OF PARENT OR gUARDIAN

DATE

(if participant is 17 years or younger)

SIgNATURE OF MEMbER(s)

DATE

YMCA Mission: To put Christian principles into practice through programs that build healthy spirit, mind and body for all.

Fee Assistance: The YMCA seeks to make its services available to all persons. Contact the Membership Department for more information.