Fillable Family Membership Application Form printable pdf download

YMCA OF BOULDER VALLEY BEFORE & AFTER SCHOOL PROGRAM

FAMILY MEMBERSHIP APPLICATION & PAYMENT OPTION FORM

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YEAR-ROUND PLAN (FREE through 8/15/2016)

SCHOOL-YEAR PLAN (50% Discount through 5/31/2016)

Parent/Guardian 1 Name __________________________________________________________DOB________Gender _________

Address______________________________________City _______________________________State________Zip____________

Home Phone______________________Cell Phone______________________Email_______________________________________

Parent/Guardian 2 Name __________________________________________________________DOB________Gender _________

Address______________________________________City _______________________________State________Zip____________

Home Phone______________________Cell Phone______________________Email_______________________________________

Emergency Contact___________________________Relationship____________________________Phone_____________________

Children’s First & Last Names (ages 18 & under)

Gender

DOB

School

Grade

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1.)______________________________

____

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2.) ______

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3.)

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4.)

Membership Agreement and Photo Release

In applying for Y membership, I agree to cooperate with others in supporting the YMCA mission, goals and objectives and to abide by

the policies and procedures set forth by the YMCA of Boulder Valley Directors. In addition, the Y reserves the right to screen for and

deny access OR membership to any person who has been convicted of any crime involving unlawful sexual conduct or are a

registered sex offender. I do hereby agree to hold free from any and all liability the YMCA and its officers, employees and members,

and do hereby myself, my heirs, executors and administrators, waive, release and forever discharge any and all claims for damages

which I may incur, or which hereafter accrue to me, arising out of or connected with my participation in any of the activities of the Y.

I understand that I am responsible for my belongings at all times. I understand that YMCA membership dues are non-refundable,

membership privileges my not be transferred from one individual to another, and that the YMCA may revoke my membership at any

time. I give my permission and consent to the use of any photographs, videotapes or other media record of my participation at the

YMCA of Boulder Valley for any lawful purpose, without compensation to me or on my behalf. If I choose not to be photographed,

videotaped, or in other recorded media, it is my responsibility to inform the photographer and/or remove myself from the picture.

Payment Autodraft Pay Options and Terms

By providing my signature below, I agree to the terms and authorize the YMCA of Boulder Valley to charge my account on a monthly

basis as fulfillment of my monthly membership plan. I understand it is my responsibility to update any changes or expiration dates

30 days before the draft date. If I wish for my payment plan to change, I must submit a new Payment Authorization Form 30 days in

advance of draft date. To cancel my membership I will give the Y written notice 15 days in advance of my payment date. I am

responsible for payment if 15 day notice is not received. If my payment obligation is not met, I will be unable to utilize Y facilities

until payment is made. If a membership billing error has occurred, I will notify the Y within 60 days of the said error by filling out a

refund request form. The Y will not refund membership dues dating back longer than 60 days. The Y will provide 30 day notice to me

of any applicable rate change. School-Year Plan: Your membership will automatically cancel on May 31 or when you cancel your

membership or care. Year-Round Plan: Your membership will automatically cancel on August 15 or when you cancel care.

Credit/Debit Card

Credit/Debit Card Holder Name ________________________________________________________________________________

Visa MC Amex Disc Card # _______________________________________________ VIN Code ________ Exp. Date ____________

Responsible Party Name (print) _________________________ Signature __________________________________Date ________

Bank Draft: Attach a voided check

Account Holder Name ________________________________________Name of Bank____________________________________

Routing/Transit Number______________________________________Account Number___________________________________

Responsible Party Name (print) _________________________ Signature __________________________________Date ________

Print Name_________________________________Signature___________________________________Date: ________________

OFFICE USE ONLY: Intake Name________________________Intake Date_________Date Entered_________Entered Initials________

Family Membership Application Form

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