Membership Registration Form - City Of New York Department Of Parks & Recreation

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MEMBERSHIP REGISTRATION FORM
New Member _____ Renewal_____
RECREATION CENTER: ___________________________
Circle One: Adult
Senior
Youth
Child
NAME __________________________________________________
Date of Birth _______________________
ADDRESS ____________________________________________________________________________________
CITY ________________________________________STATE _________ZIP CODE ________________________
PHONE (____)____________________________
E-MAIL ADDRESS __________________________________
IN CASE OF EMERGENCY PLEASE NOTIFY:
NAME ____________________________________________ RELATIONSHIP ____________________________
PHONE (____)__________________________________ALTERNATIVE PHONE (____)_______________________
SIGNATURE _________________________________________DATE ____________________________________
Available Membership Packages
(Please check one)
Adults Ages (Ages 18-61)
Seniors (Ages 62+)
Pool & Recreation Centers
$150.00 Annually
_______
Pool & Recreation Center - $25.00 Annually _______
Pool & Recreation Centers
$ 75.00 6 Months _______
Youth (Ages 13 – 17)
Recreation Centers Only
$100.00 Annually
_______
Pool & Recreation Center - FREE WITH ID _______
Recreation Centers Only
$50.00 6 Months _______
Child (Ages 1 – 12)
Lost Card
Pool & Recreation Center - FREE WITH ID ________
Replacement Membership Card
$5.00 Fee
_______
Conditions of Membership
Program & Fee Changes:
Program schedules and rates are subject to change as needed at the discretion of the City of New York Parks & Recreation Department. This does not apply to general
center membership fees. When possible, advance notice will be provided.
Facility Maintenance and Upgrades:
The City of New York Parks and Recreation attempts to keep its facilities open as much as possible but it is necessary to close certain programs areas for short periods of
time for repairs and restoration. The staff will make every attempt to allow our members access to alternative areas during necessary upgrades and or maintenance of
the facility.
Security:
All members must show their picture identification card at the FRONT DESK before entering the activity center. A $5.00 replacement fee will be charged for lost
membership cards. Members must utilize lockers and provide a good lock for their personal belongings. Members must be in proper athletic attire to exercise or
participate in sports activities.
Drug Policy:
No drugs, alcohol, smoking, gambling, weapons, violence, profanity or otherwise unacceptable behaviors is permitted.
Food and Beverages:
Food and beverages are only allowed in designated areas. Water in plastic bottles is permitted. Glass bottles are not permitted in the Center at anytime.
I hereby acknowledge that I have received the Membership Policies and Conditions of Membership.
Member Signature ______________________________________________________________________Date:____________________________________
(Parent Signature if under 16 years old)
Print Name____________________________________________________________________________
PLEASE NOTE-MEMBERSHIP & PROGRAM FEES ARE NON REFUNDABLE AND NON TRANSFERRABLE
Official Use Only
Payment Method:
:
Check # ___________
Money Order # ____________
Credit Card
Visa, Master Card, American Express, Discover
Credit Card # (Last Four Digits)______________________________Amount __________________ Expiration Date: ____________
Verified Two Forms of Photo Identification:
Please Circle:
Valid Driver’s License
Passport
ID Card
Other

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